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IS^Biik 




GIFT 
Dr Adelaide B roim 



lANfeMcDCALimRARY 
^.ORDUKIVWSKY 

5J;;Sb>.CAUF. 94305 



GYNECOLOGICAL DIAGNOSIS 



GYNECOLOGICAL 
DIAGNOSIS 



BY 

WALTER L. BURR AGE, A.M., M.D. (Harv.) 

Fellow- of the American Gynecological Society ; Mcml)er of the Obstetrical Society of 
Boston ; Consulting (rynecologist to SL Elizabeth's Hospital ; Formerly Vbiting 
Gynecologist to St. £lizal)eth*8 and the Camey Hospitals ; Electro- 
Therapeutist and Surgeon to Out- Patients, Free Hospital 
for Women; Qinical Instructor in Gynecology, 
Hananl T^niversity, and Instructor in 
Operative (»ynecol«gy in the 
Boston Polyclinic 



WITH TWO HUNDRED AND SEVEN TEXT ILLUSTRATIONS 




NEW YORK AND LONDON 
D. APPLETON AND COMPANY 

1910 



Coptright; 1910, by 
D. APPLETON AND COMPANY 



FRINTED IN NEW YORK, U. B. A. 



" Find out the cause of this effect — 
Or rather say, the cause of this defect. 
For this effect defective comes by cause." 

— Hamlet f Act ii. Scene 2. 



PREFACE 

Some years ago a prominent surgeon who had been atteading one 
of tny clinics, remarked when the elinic w^aa over: ** 1 think I imder- 
8tand the treatment and I know how to do most of the gynecological 
operations, but where I find great difficulty is in the tliagnosis." 

At the present time the medical profession is devoting an ever- 
tncrcddtng amount of attention to diagnosis, and it seems fitting to 
describe at length this somewhat blind subject, gynecology, for the 
benefit of those who have not had an opportunity to study it in the 
special hospitals and clinics, 

A practical text-book, embodying simplirity of tcclmique and 
concise statement of esscntialH^ ha^* l>een the aim. The methods of 
procedure of the pathological and bacteriological laboratories have 
been omitted because of the assumption that the physician in making 

' m diagnosis has always at his ronmmnd the services of a trained 
pathologist and bacteriologist, or can consult text-books devoted 
exclusively to thpse subjects. The attempt has been made to keep in 
the background the rare diseases which are of so much interest to the 
^lecialist and to give prominence to the common affections usually 
met by the general practitioner. While the book is written entirely 
fram the clijiical point of view, the salient points of the anatomy 
the latest \dews of the pathology' have been summarized at the 

jbegmning of each chapter, and the literature has been scanned for new 

f ideas of value to the practitioner. 

The differential diagnosis is entered into extensively and is sum- 
jDArixecl in many places in the form of tables of parallel columns. 

Particular attention has been paid to the diagnosis of the diseases 
of the bladder and of the rectum because of my belief that these 
OJ-gana are too often neglected. A chapter on diseases of the l)reast 

jfhms been includetl because the breast is a part of the reproductive 
pm in w'oraen and has intimate relationship with the uterine 

[Ofg^ivi^ The importance of the recognition of uterine disease in early 

l]sfe| which, wiien undiscovered, frequently causes disastrous results 
later, has led to the writing of the chapter on the g}^necological affec- 
tiona of infancy and childhood. In the preparation of this chapter 
I have been fortunate in having the assistance of my friend, Dr. 




viii PREFACE 

John Lovett Morse, who kindly revised the manuscript. The chapter 
on the menopause is an attempt to shed light on this important but 
little understood period of woman's life. 

An original feature of the book is an alphabetical index of illus- 
trations — of which there are two hundred and fifteen — ^in the front. 
Thus the reader can find any desired figure without laboriously 
going through the entire list. The attempt has been made to place each 
figure next to the text it illustrates and all references to figures, as well 
as to subjects cited in other parts of the book, are accompanied by 
page numbers. Every chapter is headed by a rdsum^ of its contents 
with page references, and all the illustrations, as well as the titles of 
the subject-matter, are also included in a vcrj^ full index at the end. 

The views here expressed and the methods described are those 
that have found favor in my practice, and they arc put forward not 
with the feeling that they arc new, original, or all-inclusive, but that 
having proved useful to me they may help others also to unravel the 
knotty problems of gynecology. 

My thanks are due to Dr. Howard A. Kelly, Dr. E. C. Dudley, and 
the other authors who have kindly loaned illustrations from their 
works; to Dr. Henry T. Hutchins for revising the chapter on malig- 
nant diseases of the uterus and the section on the collection of the 
discharges and tissues for microscopic examination; to Dr. Howard 
W. Beal for assistance with the section on indirect cystoscopy; to 
Miss Florence L. Spaulding and Miss Ruth O. Huestis for original 
drawings; and especially to Messrs. D. Applcton and Company, 
who have shown never-failing courtesy and who have assisted in every 
possible way in the making of the book. 

Walter L. Burrage. 
Boston 



CONTENTS 



PART I 

GENERAL CONSIDERATIONS 

PAGE 

Chapter I. Introduction 3 

Chapter II. The Clinical History 6 

Chapter III. The Interpretation op the Cunical History . . 9 

Chapter IV. The Physical Examination 23 

I. The preparation of the patient. — II. The prepar- 
ation of the examining table. — III. The exam- 
ination: 1. Preparation of the physician and 
placing the patient on the table. 2. Inspection 
of the external genitals. 3. Palpation. 

Chapter V. The Physical Examination (CorUinued) 43 

III. The examination (corUmued): 3. Palpation 
(continued). 4. Odor as a diagnostic sign. 5. The 
collection of the discharges and tissues for micro- 
scopic examination. 

Chapter VI. The Physical Examination (CorUinued) 64 

III. The examination (continued): 6. Inspection of 
the abdomen. 7. Palpation of the abdomen. 
8. Percussion of the abdomen. 

Chapter VII. The Physical Examination (Concluded) 77 

III. The examination (continued): 9. Instruments 
and their use in diagnosis. 

Chapter VIII. The Investigation of the Urethra, Bladder, and 

Ureters 99 

Chapter IX. The Investigation of the Rectum 121 

Chapter X. The Significance of the Chief Symptoms of Pelvic 

Disease 127 

ix 



CONTENTS 



Chapter XI. 
Chapter XII. 
Chapter XIII. 

Chapter XIV. 
Chapter XV. 
Chapter XVI. 

Chapter XVII. 
Chapter XVIII. 
Chapter XIX. 
Chapter XX. 
Chapter XXI. 
Chapter XXII. 

Chapter XXIH. 
Chapter XXIV. 
Chapter XXV. 
Chapter XXVI. 
Chapter XXVII. 
Chapter XXVIII. 

Chapter XXIX. 



PART n 

SPECIAL DIAGNOSIS 

PAOK 

The Diagnosis of Endometritis, Including Gonor- 
rhea and Erosions of the Cervix Uteki . . . 165 

The Diagnosis of Pelvic Infl.\mmation (Pelvic 

Peritonitis and Pelvic Cellulitis) . . . 187 

The Diagnosis op Congenital Anomalies of the 
Uterus, Laceration of the Cervix Uteri, and 

Diseases of the Uterine Ligaments .... 197 

The Diagnosis of Malpositions of the Uterus . 215 

The Diagnosis op Fibroid Tumors of the Uterus 244 

The Diagnosis of Malignant Diseases of the 

Uterus 266 

The Diagnosis of Diseases of the Ovaries . . 284 

The Diagnosis of Diseases of the Fallopian Tubes 324 

The Diagnosis of Extra-L'terine Pregnancy . . 340 

The Diagnosis of Diskasf-s of the Vagina . . . 354 

The Diagnosis of Diseases op the Vulv-^ . . . 388 

The Diagnosis of Uterine Pregnancy, Abortion, 

AND Hydatidiform Mole 417 

The Diagnosis of Diseases of the Urethra . . 444 

The Diagnosis of Diseases op the Bladder . . 457 

The Diagnosis of Diseases op the Ureters . . 486 

The Diagnosis op Diseases of the Rectum . . 494 

The Diagnosis of Diseases of the Breast . . 531 

The Diagnosis of the Gynecological Affections 

OF Infancy and Childhood 555 

The Menopause and Old Age 587 

INDEX 627 



LIST OF ILLUSTRATIONS 



FIO. PAOE 

Abdomen, cavity of, shape of 86 221 

division of, into quadrants and indication of bony landmarks . 18 65 

organs of, origin of tumors in 129 304 

Anal canal 191 495 

cast of 192 496 

Anal region, diagram of 195 515 

Applicator, uterine 37 93 

Ascites, abdomen of, seen in profile 131 307 

cross section of , dorsal position 132 310 

lateral position 133 311 

Bartholin's gland, cyst of left 174 409 

Bartholin's glands, abscess of 176 411 

abscess of ducts of 175 410 

Bladder, ballooned by air, patient in knee-chest position 54 112 

base of, showing diverticula 185 458 

norma], laid open from in front 51 106 

overdistended 84a 217 

papilloma of 190 482 

stone in 186 463 

tuberculosis of ureteral orifice in 187 469 

varix of 188 474 

Bladder phantom, for practising cystoscopy 58 118 

Blood vessels, uterine and ovarian 8 47 

Body, vertical median section of 6 44 

of childbearing woman 84 216 

Breast, diffuse bilateral hypertrophy of 201 541 

(liKsection of lower half of, showing milk ducts 198 534 

division of, into quadrants 200 538 

lymphatics of 199 535 

right, vertical section of » 197 533 

scirrhous cancer of 202 547 

Calibrator, meatus, Kelly 44 101 

Carunculff myrtiformes 165 397 

Catheter, bladder, long silver 43 101 

ureteral, Kelly 48 103 

Orvix, adeno-cardnoma of canal of, early stage HI 268 

cancer of , early stage 110 267 

erosion of, with lacerations 69 185 

fibroid of 108 254 

hypertrophic elongation of 88a 225 

xi 



3ai LIST OF ILLUSTRATIONS 

no. PAGE 

Cervix, laceration of, bilateral, with erosions 79 205 

crescentio 81 207 

stellate 80 206 

unilateral (diagram) 83 209 

with eversion of lips (diagram) 82 209 

prolapse of 88 224 

squamous-celled cancer of, early stage 110 267 

supravaginal, elongation of 88 224 

Controller, current, for use with electric cystoscope 57 117 

Curette, uterine 31 90 

Cylinder, vertical, filled with fluid, representing abdominal cavity . 7 45 

Cystocele 148 367 

diagram of 148a 368 

Cystoscope, bladder, Kelly 49 104 

ureter, Nitze 56 116 

Cystoscopy, modified knee-chest position used in 53 111 

removing urine from bladder in, by suction apparatus 55 113 

Decidua, uterine, in extraruterine pregnancy 143 345 

Depressor, vaginal. Hunter 29 89 

Dilator, urethral, double-ended, Kelly 45 102 

uterine, Wathen . 34 92 

uterine. Hanks 33 91 

Endometrium, normal ^65 167 

Enteroptosis, body pose in 19 67 

Evacuator, bladder, Kelly 46 102 

wash-bottle, Kelly 55 113 

Extra-uterine pregnancy, ampullar, early 140 341 

mole and fetus removed 141 342 

ampullar, late 145 350 

isthmial, section of uterus of 146 352 

Fallopian tubes, development of, in fetus 71 198 

Fissure in ano 194 504 

Fistula in ano, blind internal 196a 517 

complete 196 517 

Fistulae, genital, scheme of, after Dudley 189 476 

after Gilliam 155 385 

Forceps, bladder, alligator 50 105 

curette, Emmet 30 89 

rectal, alligator 62 125 

uterine dressing, Bozeman 23 83 

vulselliun 25 84 

Gauze records of abdominal tumors 20 75 

Genital organs, development of, five diagrams illustrating . . 158-162 395 

external, at beginning of third month 157 392 

Gland, Bartholin's, cyst ofleft 174 409 



LIST OF ILLUSTRATIONS xiii 

no. PAGE 

Glands, Bartholin's, abscess of 176 411 

abscess of ducts of 175 410 

Hand, examining, showing protective sleeve 2 31 

Hegar's method of palpating pedicle of ovarian tumor 126 301 

sign, bimanual palpation for 179 425 

Hematocele, pelvic 142 343 

Hcmatocolpos, diagram of 171 398 

Hcmatometra, diagram of 172 398 

Hematosalpinx 139 'S'<i5 

diagram of 173 399 

Hemorrhoids, types of • . . . 193 499 

Hydatidiform mole 182 442 

Hydrosalpinx 138 334 

Hymen, different forms of 163-170 397 

Interstitial pregnancy 144 346 

Irrigator, uterine, Bozeman-Fritsch 35 92 

Isthmial tubal pregnancy, section of uterus of 146 352 

LiG.vMENTS, utero-sacral, course of, in intraligamentous tumor . . 135 317 

in retroperitoneal tumor 134 316 

Mattrfty, precocious, case of . . 207 565 

**Milkline," 200 538 

Os. external, parous 66a 169 

virginal 66 168 

Ovaries, infantile 117 286 

Ovary, cyst and timior regions of 120 290 

c>'st of. adherent, arrangement of peritoneum in 124 292 

intraligamentous, arrangement of peritoneum in 123 292 

pedicle, arrangement of peritoneum in 122 292 

very large, showing emaciation and '* facies ovarina " . . . . 125 294 

normal, pedicle, arrangement of peritoneum in 121 292 

of mature woman 118 287 

senile 119 289 

tumor of , cross section of body of 127 302 

tumors of, Hegar's method of determining relation of, to ut«nis . 126 301 

pedicle, formation of (4 diagrams) 121-124 292 

Ovary and tube seen from behind 116 285 

Parovarii-m, large cyst of, seen in profile 128 303 

Peh-imeter . . / .... 42 98 

Pelvis, contents of, from aV>ove 9 48 

female, normal 9a 50 

showing accewibility of contents to pali)ation 10 52 

with hand in position as for vaginal examination 4 37 

floor of, diagram showing structures of 150 373 

of new-bom child, longitudinal median section of 204 558 



xiv LIST OF ILLUSTRATIONS 

VIG. PAQK 

Perineum, laceration of, complete median 151 374 

partial lateral 152 375 

Peritoneum, reflections of folds of, in pelvis 70 189 

Position, dorsal 3 32 

knee-chest 13 56 

bladder, vagina, and rectimi ballooned by air in 54 112 

modified for cystoscopy 53 111 

side-view, showing vertical thighs 14 57 

lithotomy 15 58 

raised pelvis 16 59 

Sims 11 53 

diagram of 12 54 

standing 17 60 

Precocious maturity, case of 207 565 

Pregnancy, extraruterine. See Extra-uterine pregnancy 

interstitial 144 346 

tubal, early ampullar, abortion in 140 341 

mole and fetus removed from tube 141 342 

bthmial, uterus of 146 352 

late ampullar, four months' 145 350 

section of uterus, showing decidual modiflcation in 146 352 

Probe, uterine 22 82 

Procidentia 87 223 

Proctoscope, long 61 124 

short 60 123 

Pyosalpinx 137 333 

Rbgtocelb 149 369 

diagram of 149a 370 

Rectum, ballooned by air, patient in knee-chest position 54 112 

lower part of , diagram of 195 515 

SAU»iNGins, tuberculous 136 331 

Searcher, ureteral, Kelly 47 102 

Soimd, uterine 21 78 

Separator, urine, Luys 59 119 

Speculum, bivalve. See Speculum, vaginal, Brewer and Graves 

rectal, Sims 63 126 

uterine, Burrage 36 93 

vaginal. Brewer 26 87 

Edebohls 32 91 

Graves 27 87 

Sims 28 88 



Table, examining 1 27 

Tenaculimi, uterine 24 83 

Touch, bimanual, diagrammatic drawing 5 38 

Tubercles of bladder waU 187 469 



LIST OF ILLUSTRATIONS xv 

no. PAGE 

Urkter, orifice of , jet of urine spurting from 52 107 

Urethra, caruncle of * 184 454 

mucous membrane of, prolapse of 183 449 

Uterine organs of an infant at birth seen from above 205 562 

Uterus, anteflexion of, in the little girl 90 230 

pathological 91 231 

bicomis 74 199 

bicomute. one external os, two uterine cavities 78 201 

bipartitus 72 199 

body of, adeno-carcinoma of, early stage 112 269 

horizontal section of upper part of 67 171 

sarcoma of 113 279 

cavity of, Kelly's methods of exploration of, exploring with finger 41 97 

incising ant^^rior wall 39 95 

transverse incision anterior to cervix 38 94 

laid open 40 96 

chorioepithelioma of posterior wall of 114 281 

development of, in fetus 71 198 

didelphys 73 199 

douV)le. with double vagina 147 358 

fibroids of. intt^rstitiul and submucous 104 248 

intraligamentous 105 249 

large tumor filling pelvis and simulating pregnancy .... 109 256 

multiple 102 246 

polyp in vagina, large 107 252 

submucous, large, showing distortion of uterine cavity .... 106 250 

simulating inversion 101 245 

pedimculated, simulating inversion 99 241 

simulating partial inversion 95 241 

suV)serous. side view of abdomen containing large tumor . J . 103 247 

tumor of cer\'ix 108 254 

fundus of, height at various wet»ks of pregnancy 130 306 

inversion of acute puerperal 93 239 

complete 98 241 

with |)etlunculateil subserous fibroid of abdominal evolution . 100 241 

partial 97 241 

ttiiLse*! by suV)mucous fibroid 296 241 

of left horn 94 241 

normal. |H>sitionof 6 44 

pregnant, enlargement of, in late pregnancy 181 428 

pregnant at sixth week, diagrammatic side view, during contraction 178 423 

during relaxation 177 422 

section of 178 424 

prolapse of 87 223 

partial 89 227 

recon.stniction of, showing shape of uterine cavity and cervical 

canal 64 166 

ret roposition with anteflexion 91 231 

retroversion of . 92 235 

caused by overdistended bladder 84a 217 



xvi LIST OF ILLUSTRATIONS 

na. PAGE 

Uterus, sarcoma of 113 279 

section of, in isthmial tubal pregnancy 146 352 

transverse longitudinal 68 172 

septus 75 199 

unicornis , 76 199 

with accessory comu 77 199 

Vagina, ballooned by air, patient in knee-chest position 54 112 

chorioepithelioma of, metastatic 115 282 

cyst of anterior wall of 154 381 

cyst of posterior wall of 153 380 

development of, in the fetus 71 198 

double, with double uterus 147 358 

infantile, examination of, with cystoscope 205 559 

longitudinal section of, showing S-shaped curve 85 219 

prolapse of 88 224 

Vulva, at beginning of third month of fetal life 157 392 

diagram of 156 389 

infantile 203 556 



PART I 
(JENERAL CONSIDERATIONS 



CILIPTER I 



INTKODUCTION 



Diagnosis, tho foundation of gynecology, h elusive. The con- 
sultant frequently hears it said l)y the attending physician^ ** Doc- 
tor, I know how to do this operation, but what puzzles mc is to 
know when it is intUcateil" 

The etiueateil toueh is the keystone of the diapiostie arch; 
gymptomutology, sight, instninientation* niicro^eopie fimlings, are 
but accessories. To train the toueh reciuires time and application. 
Ai? in learning any handicraft, the beginning is of great inipoilanee. 
Tho:<e who neglect to perfect themselves in the proper technit[Ue 
at the fttart, who never aefjuire *' geKxl fonn " as they say in athletics, 
never progress beyontl a mtxlerate degi*ee of excellence. The 
, practitioner who pei-sists in making the bimanual examination with 
the i^atient in bed or on a yielduig surface, or neglects to incoMimodc 
her to the extent of causing to be Io*jsene<i all clothing alx>ut the 
wai8t , never bi'comes. a good diagno^lician. The rc^asons for this 
will apjiear later. 

There is no department of medicine in which the patient is less 
able to judge from her own observation of the corriH^tness of the 
^diagnosis than in gpiecology. Unlike tlie dermatologist, for ex- 
ample, the gjTieeologist docs not have trained ufjon his work the 
critical eye of his patient. 

She is unable, also, to judge of the nature of the treatment em- 
ploye*!. It is espc^eially easy for a physician who has made an error 
in diagnosis to |)ersist in a chosen line of treatment without dis- 
covering his mistake^ for the illations between eaust* and efiTect are 
often incmi sha<lowy; also, consultations are relatively infreipient 
in this clepartinent of medicine. Because of the delicate nature 
of the confidences calkMi for. and the sensitive portion of the 
anatomy iuvoIvkI, the patient shrinks fmtn subjecting herself to 
repeated examinations at the hands of different physicians. 



4 INTRODUCTION 

We have to do in this book with the question of diagnosis alone 
and it will be my endeavor to point out how best to make it. More 
stress wall be laid on the interpretation of symptoms and signs in 
the light of experience than is usual in text-books on gynecology 
because it is thought thereby to help the practitioner. 

That pathological conditions may exist without any symptoms 
at all should never be forgotten. For instance, a woman may have 
a double uterus, detected for the first time at the gynecological 
examination which follows labor, or a patient may have a small 
dermoid tumor of the ovary, discovered only when she comes to 
the physician to learn why she has never had children. 

A judicious combination of the deductive and inductive methods 
seems to be the most practical way of presenting the subject; a 
result accomplished by describing the steps of the examination and 
the processes followed in arriving at a diagnosis, as nearly as may be, 
as they occur in actual practice. 

Particular attention is paid to the minutiae of the history-taking, 
the management of the patient, and the smallest details of the ex- 
amination, because of my belief that matters which seem trivial to 
many are in reality the solid groundwork of a correct diagnosis. 

Mistakes in diagnosis are unavoidable even in the exix»rience of 
the most expert. To make a mistake because an inadequate ex- 
amination was made or no examination at all is an unpardonable 
sin. Experience teaches that finality in diagnosis is not always a 
possibility in gynecology, and even after the most painstaking 
history, analysis of the symptoms, and physical examination, wp 
may fail to distinguish between two or three possible conditions. 
Our object is to reduce the uncertain cases to a minimum. 



CTHPTER II 



THE CIJXHWL HLSTORY 



cthod of getting I be history, p, A. Casp-rec*jrd systems, p. 0* Form for 
'^reciirdd, p. 6, 



METHOD OF GETTING THE HISTORY 



I 



Many busy praetitionors slight the clinical hktofy, the taking 
of which should prtTedc evtiy physical examination. This is 
a mistake which carries its own retrilnitiou in the form of a slij)- 
ghoil tUai^nosl'^. A clear antl exhaustive history not only serves as 
a guide in making the physical exaiiiination, but also develops 
gynjptonis which otherwise may Ix' overlookcni. There are few 
cafies wWch are not Ijetter diagnosed by a careful preHniinar}' 
(|umtioning of the patient. The physician gains liis patient s con- 
fi4i«?nce, so necessary for a successful phy^^ical examination. If she 
iKK-omi^s prolix or strays from the important [loint, a <[uestion will 
often bring her back. It is well to note especially, |>erhai>s by 
underUning, the symptoms that seem most important to her, so 
thai in subsiH[Uent int^*rviews these may Ix* under sjiecial obser\"a- 
tion. It is generally lx»tter to talk with the fiatient alone when 
getting the history^ as there art' imi>ortant facts which will Ije 
»uppn>is4>d if a third (X'rson, whether a nurse or a relative, Im^ i)r<^ent, 
jometimc^^ it hapiwMis, however, that important facts are to f)e 
ined from the husband, and, in the case of a young girh from 
the mother, A <lesiraljle j^ractiee is to review the history after the 
physical examination in the light of the facts brouglit out by the 
examination and to cross-question the patient as to the truth. 
Avoid I as far as possible, asking leading questions ami assenting 
to*> n*AiUly to the answers. Be sm'e that the answers represent the 
truth. 

5 




THE CLINICAL HISTORY 



CASE-RECORD SYSTEMS 



A good method for case records is the envelope, card-catalogue 
system. A filing cabinet with several drawers is obtained. Large, 
ungummed envelopes, and also a si^t of cards just fitting into the 
envelopes and the drawers as well, are procured. For use at the 
bedside it has been my custom to carry in a leather pocket-case a 
block of prescription blanks, six by four inches, which fit the en- 
velopes of my filing cabinet. At the office I use cards of the same 
size. Every card and envelope is marked on the left-hand top 
comer with the patient's name and filed alphabetically in the 
cabinet. One advantage of the envoloix^ system is that additional 
memoranda, such as notes on tn^atment and other data, may be 
filed in the same envelope, and it is not necessary to copy the notes 
taken at the bedside bc^fore filing thc^m. 

Many gynecologists have printed case sheets, either in a book or 
as loose pages or cards. It is well to have some schedule to follow 
so that the same order may be observed in all cases and important 
facts may not be omitted. To the Ix^ginner a printed form is in- 
valuable, but to the physician of experience it is hardly worth while 
to take up desirable room on the cards with printing which may be 
of no use in many of the cases. The object is to get a schedule in 
mind, rather than to have it printed before you. 



FORM FOR CASE RECORDS 

Date: 

Name in full : 

(In the case of a married woman both own first name and hus- 
band's first name for purposes of future identification.) 
Address : Nationality : 

Occupation : Age : 

Social Condition : Single. Married, (how many years) 

Widow : (how many years) 
Children : (how many and ages) 

Miscarriages or abortions : (number, and at what weeks or months 
of pregnancy.) 



FORM FOH C.\SE RECORDS 



Family History. — General |>mllspoi?ition to raiicer, lung trouble, 
heart clii^rase, kidney disease, or rheunmti.^nh If the parent.^ arc 
dead, what were the causes of death. Early or late occurrence of 
the fij^t menstruation and of the menopause, or tlie oecuri'enee of 
dysnK*iion*heft or uterine disease in gisters or female relatives, 

Preiious Hi-story. — Sfx*cial reference to g\'necolo^cal affections; 
a^ attacks of vnilvar inflammation, or smarting with mictmition, 
as Lnilicating gonorrhea: ''inflammation of the bowels/* as indicat- 
ing pelvic inflammation: lack ot control over the bowels or blatlder, 
showing injury of the siihincter ani <»r of the pehic Hoor; the 
account of any operation which may liave been performed on the 
genital organjs. The infectious diseases may point to inflammatory 
afTections of the %*ulva and vagiiia in childhood 

MeJu4riuUion. — Age at which first menstiTiation occurred ; whether 
normally established, the subseijuent rh3l:hm, duration, quantity, 
and quality of the flow; whether accompanietl by pelvic pain, if 
iK), the situation, character, anil duration of the pain, also whether 
before, during, or after the flow; whi*ther distm-bances of other 
functions at the time of menstruation, as naust^a, headache, dc^ 
presssion of spirit^s; any recent irrc»giilarities in the rh}ihm, t)uan- 
tity, or character of the flow; intermenstrual pain, if so, exact dates 
of beginning and end of pain. Is menstruation accompanied by 
fc?ucorrhea, or not. 

Vaginal Discharge. — Character, amount, when most in quantity, 
duration. 

Pirin, — Other than menstnml, situation, duration, I'liaracter. 

Con/memento, Miscarria{i€s, and Af}orti(ms, — Labors normal, rapid, 
tedious, or instrmnental ; whether injuries received or symptoms 
•tuffered: convalescence normal or not; stitcht^s taken, ft*ver 
following, MLscarriages or abortions, dates of occurrence and at 
what w*et*ks of pregnancy : suppost^l cause or »'auses ; atti^nded by 
much flowing or fever; convalescence, good or bad. 

Bladder Symptoms. — Frecjuency of micturition by day and by 

2:ht; smarting on urination; control of urine on laughing and 

ighing and on standing and walking: pain in region of bladder 
on micturition; color and <[uantity of urine |>ai^se<^L 

P3Fie$enl Ithhess, — Duration; jjarticulars as to present sjonptoms 
such aa puin, situation, character; leucorrliea, when first noticed, 



8 THE CLINICAL HISTORY 

character, as thin, glairy, thick, purulent, bloody, or offensive; 
whether constant, or before and after menstruation. 

Date of the Beffinning of the Last Menstruation. 

Abdominal Swelling. — When first noticed, progressive increase 
in size, stationary or smaller, painful or not. 

Bowds, — ^Regular movement every day or constipated; full 
action or scanty; liquid, semi-solid, or solid stools; offensive odor; 
gas in bowels; blood, mucus, or pus with the stools; painful de- 
fecation. 

General Health. — ^Appetite, digestion, sleep; whether an increase 
or decrease in body weight; headache; backache. 

The General Appearance of the patient should be noted as 
regards height, approximate weight, complexion, color of lips, 
peculiarities of form, if any. 

Analysis of Urine. 

Treatment Advised. 



CHAPTER III 



THE INTERPRETATION OF THE CLINICAL IHSTORY 

Tlic address, nationality, antl occupalion, fi. 9. A^\ f>. 9. Social 
eomiition, p. 10. Dy imreuniii, p. H (1nklrcii» 11. Family history, p. H. 
Previous history p, V'i. CoiistitulioiMil diiseases, p. H. Chief complaint 
and present illness, p. 15. Menstruation, p, 13: Puberty, p. H; The 
nienopause. p. 16; The atrophic changes in the genital organs and the 
body alterations of the nienopayse, p. 17. Vaginal distl large, p. 18. Pain, 
p. 1ft Backache, p. 18, Muscular rheuniatisni, p. 1!*; Coc<"ygodynia. 
p. 1»; Pains in the groins, p. 19. Alj<li)niintil swelling, p. ^>, Bladder 
s)i]]pioms, p. iO, The l>owels, p. t\. Present illness, p, t^. 



This is a chapter of probabilities : not instructions how to make 
an offliaml diagnosis, but a ^^ifting of ilic ovidtiin* as it is preseiitetl, 
the cUagnot^iH toeing held in reserve until after the physieal examina- 
tion, ami until after any supph^nientary^ e\itlence has Ix-en elieited 
in the way of answers to questions which may be suggested by the 
examination. 

A knowledge of the normal eon^litions h essential, if the value of 
tfie abnormal symptoms is to Ik* e^iinatect correctly. 

The Address. — This is impurtant not only as a matter of business 
but as showing the possible effect on the patienCs health of a healthy 
or an unhealthy locality. 

nationality. — The colore<l race is especially prone to fibroids. 
Cancer Ls seldom foimrl in a negress. 

Occupation* — Confinement in poorly lighted and ventilated work- 
gbopg^ long working hours, heavy lifting, insufficient focxl and pro- 
ved standing on the feet aggravate, if they do not caus4% pelvic 
^disorden^a On the other hand, a seilentary life with no real exercise 
may act as a contributory cause of j^Hdvic tlisease. 

Age.— The age of the patient suggests the sfx^cial disturlmnces 
found in the various e|>ochs of life. In infancy malfonnations and 
inflammations of the lower genital tract are to Ix* ex|XH'ted. At 
ihiii time the infections are generally limited to the vulva and 
vagina, and tumors, displacements, and traumatisms seldom exist. 
Vulvo>va^nitis is not uncommon in little girk. 



10 INTERPRETATION OF THE CLINICAL HLSTORY 

Failure of the menses to appear previous to the sixteenth year 
should excite no apprehension ; after that it is apt to indicate under- 
development of the uterine organs. 

During the period of sexual maturity nearly all of the lesions of 
the genital organs may be found. The effects of gonorrhea are 
seen most often between the ages of twenty and thirty. Tumors 
of the breast are most frequently malignant between the ages of 
forty and sixty. Under the age of thirty-five a large alxlominal 
tumor is more likely to be ovarian; after that age it is more apt to 
be a uterine fibroid. 

A patient suffering from uterine hemorrhage more probably has 
endometritis or a polypus if under twenty; a polypus or some 
condition resulting from gestation, from twenty to thirty; fungous 
endometritis, polypus, or fibroids from thirty to forty ; fibroids and 
malignant disease from forty to fifty. After fifty, malignant 
disease is the probability. 

Social Condition. — Congenital malformations may be brought to 
the patient's attention for the first time after marriage. Certain 
inferences may be drawn from the single or the married state of a 
patient as regards the cause of menorrhagia or metrorrhagia, as 
shown by the tables on pages 137 and 139, Chapter X., also as 
regards leucorrhea, as found on pages 144-146. Pregnancy is 
always to be considered if the pati(*nt is not a virgin. An early 
question as to the patient's social stat(% whether single, married, 
or a widow, may obviate embarrassing queries as to sexual re- 
lations and may throw light on the possible causes of her com- 
plaints. For instance, a recently married woman, always a sufferer 
with dysmenorrhea, finds the symptom aggravated and unbearable 
since her marriage. A periodic pelvic congestion, due to mal- 
position or malformation of the uterus, has been accentuated by 
the congestion which attends sexual relations. A recently married 
woman complains for the fii*st time of smarting on urination, and 
leucorrhea. Suspicion of infection with the gonococcus at once 
arises in the physician's mind. The possibility of pregnancy or 
venereal infection should never be lost sight of, notwithstanding the 
patient's statement that she is single or a widow, great caution and 
tact being exercised, however, in making inquiries. The final 
question as to the truth or falsity of the suspicion should be left 
until after the physical examination in any event, and in many 



CHILDREN 



n 



not Ix^ matle at all witliout causing serious and unjustifi- 
able trouble in the family of the patient. 

Dyspareunia.— Dyspareunia dating from the time n{ marriage 
indi(*ates smallneKs of the introitus vagime or uri'thral earuiK'lt*, 
if the pain is at the Irx^ginnitig of t^oitus. If the pain is ex[>prienceil 
after the penis has bet^n introduceil into the vagina the cause is 
apt to be pehie inflammation or a tender cervix or ovary. 

Children.^SterUity.—Thv absejiee of children njay Ix^ important, 
for if a patient has been married many years and has not been 
pregnant, the inference is that the cause of the sterility re^ts with 
her and not with her husband, the latter bcnng in goal health, and 
we may expi^ct to find some underdevelopment or malformation 
of the sexual organs. If there is any doubt as to the husband's 
virility a i?peeimen of his stamen should Ix? examined for s[>erma- 
tozoa before subjecting the wife to gyiiecotogical treatment. 
(See Chapter X,, page 147.) 

Carcinoma of the cervix, common in parous women, is rare in 
nullipane, wliereas cancer of tlie Ixxly of the uterus is more apt to 
occur in wonim who have not lumio children. Coinplete or rela- 
tive st4?rility is often found in women suffering with fibroids. 

Numljer of Children, — Thi^ numlxT of children a woman has had 
is important lx*cauH<* rhild-ix'aring without a sufTieient interval of 
recuperation tx'tween the labors frequently results in some sort 
of pelvic ailment. Therefore, note the ages of the children, Th<* 
history of t»ach ronfinement is <>f the gn^atest ser\ace in determin- 
ing the origin of a i)elvic inflammation, a niisptacement of the 
utt^rus, or lacerations. A difficult forcefxs delivery followed by 
fever and a tetlious convalescence may tncan all three, though not 
nec!€ssarily* 

Mwcarrmges and Aboriiom. — A history of each miscarriage or 
abortion should be secured with reference to the birth of chiklren: 
if before, the int»'rruption of labor can not be due to injuries re- 
ceived at labor; if subsequent to a tliflicult and complicated con- 
finement, an abortion may well be cau.sed by the lalx>r. The 
probable cause of an abortion in the patient's estimation, whether 
attended by hemorrhage or fever and how long the patient was 
confined to her bed, are points to be ascertained. These facts often 
reveal the starting point of an attack of pelvic inflammation » or 
anemia and subsequent debility due to loss of blood. If rept*ated 




12 INTERPRETATION OF THE CLINICAL HISTORY 

abortions have occurred they may indicate syphilis, tuberculosis, 
or a deeply lacerated cervix. 

Family History. — How much of a role heredity plays in the 
etiology of pelvic disease is not determined. Cancer and tuber- 
culosis are found occasionally in members of the same family. It 
sometimes happens that several sisters will all have a similar lesion 
of uterine underdevelopment. I have seen three sisters, each 
suffering from marked pathological anteflexion. A premature or 
delayed occurrence of the menopause is frequently a family charac- 
teristic. So is the symptom of dysmenorrhea. Family history, as 
a rule, does not have an important influence on diagnosis. 

Previous History, on the other hand, is of great importance. We 
have noted how an abortion may be the starting point of an attack 
of pelvic inflammation to be followed, perhaps years later, by serious 
lesions of the pelvic organs. So a history of *' inflammation of the 
bowels," without assignable cause, may mean pelvic inflammation, 
the nature of the treatment employed at the time of the attack 
throwing some light on the probable diagnosis. 

An attack of soreness of the vulva associated with a purulent 
discharge, with or without smarting on urination, may well mean 
gonorrhea. 

Adhesions of the labia minora, and of the prepuce to the clitoris, 
and even imperforate hymen, may be caused by inflammation of 
the vulva in childhood due to diphtheria, scarlet fever, measles, or 
gonococcus infection. Nocturnal enuresis is caused, sometimes, 
by adhesions of this sort. Therefore, when possible, the mother 
of the patient should be questioned whether her daughter had 
vulval soreness and discharge when a child. 

A lack of control over the bowels when loose, during the months 
following a labor, leads us to expect to find injury of the sphincter 
ani, also inability to control the urine when standing, or on laugh- 
ing and coughing, make us look for injury of the vaginal wall and 
perineum and dislocation downward of the urethra. 

Injury of the pelvic floor is present if the patient complains of 
the noisy escape of air from the vagina when she suddenly changes 
the position of her boily, or strains. 

Constitutional Diseases. — All general constitutional diseases have 
a bearing both as causative agents and aggravating influences on 
pelvic disordehs; therefore they should be inquired into in getting 



MENSTRl'ATION 



18 



the historjv It 5io oftni liappi'iLs that a wdiiiaii in hrr usual good 
health is not seriously mcomnioclctl l)y a pelvic Ic^^ion and when 
pullc<l down by a long illni's.s Ls overwhelnuul by uterine .symptoms. 
The physician should move slowly in drawing eonelusions as to 
eaui^? and eflfect, and also in judging of tlie weight to tx* attached 
to the uterine lUsease. 

It should never (>e forgotten that the wliole is greater than any 
one part and that general eonstitutional disea^ses take preeedence 
over gynecological affections. It is the sick woman we are to treat. 

Chief Complaint and Present Illness* — It is very easy for the en- 
thusiastic six^cialist to [wmi his energies to the making of a new 
ostium to a dist*ased Fallopian tulx', or to the resection of a diseased 
ovary, quite forgetting for what the patient consulted him; that 
lx*CAUse» he has fouml an abnormality of the pelvic organs, this 
must of nect\ssity be the cause of the symptonis. He loses sight of 
the symptoms and doesn't always make a projKT etfoil to relieve 
thein, bcnng leil away on a futile hunt for anatomical |>erfection. 
Note, then, your [mtient's chief complaint, and whrti ycfu tuive 
finiiihed with the case, tuni to your notes, refresh your memory, 
and see whether this complaint has Imtu relieved. 

The duration and character of the present symptoms should be 
note^lt such a*^ pain, leucorrhea, ablominal swelling, ami symptoms 
relating to the lx)wels or bladder, ami do not slight the indications 
of the state of the general health as shown by the amount anil 
character of the sk»t*p, the state of the digestion, and the strength to 
accomplish customary tiaily tasks. 

Menstruation. — Menstruation may Ix* defined as a disf*harge of 
blcx)dy fluid which takes place fron} the uterus at states 1 periods 
throughout the time of s*;\xual activity in the life of women. The 
causation of the discharge is still in iloubt. 

Frankel (**Die Function des Corpus luteum/* Arckiv fur Gyn.f 
LXVIII,, 11MB, 4liH) considers that the corpus luteum in the ovary 
lia:5 a detennining influence on menstruation. It is plain that the 
ovaries have something to do with this function because, when they 
are removed, menstruation ceases. As menstruation occurs only 
in human Ix^ings and some of the higher ai>es. it is difficult to s<*ttle 
tbt* relation of menstruation tt) ovulati<>n and to the normal or 
abnormal corpus lutetmi by aTiimal exjxrimeijtation. 

The mechanisni of menstruation consists of a dia{>etlesis of 



14 INTERPRETATION OF THE CLINICAL HISTORY 

blood through delicate capillaries, newly formed in a^ thickened 
and congested endometrium, the vessels for the arterial supply 
being more capacious than those for the venous return. Some of 
the capillaries rupture and the blood flows out. 

The flow at first is mucus streaked with blood, during the height 
of menstruation it is blood mixed with a little mucus?, and toward 
the end it becomes more mucous in character. Menstrual blood 
is dark in color, alkaline in reaction, and, because of the mucus it 
contains, does not clot unless the mucus hapfx^ns to be deficient. 
The mucus renders it more watery than ordinary blood. It has 
a peculiar odor given to it by the sebaceous glands of the vulva 
which are especially active during menstruation. 

Puberty. — The average age at which menstruation is established, 
in temperate climates, is fourteen years. Variations of a year or 
two from this type occur within normal limits. It occurs earlier 
in the city girl who is subjected, perhaps, to intimate association 
with the other sex and to sexual temptations, than it does in the 
country girl, or in a girl carefully brought up in comparative seclu- 
sion. This rule applies to the lower animals. If a bull is placed 
in the pasture with a herd of heifers, heat appears earlier in the 
heifers than it does when they arc segregated. In women of strong 
sexual passion the function of menstruation is established earlier and 
lasts longer than conmion. 

The discharge of ova from the* Graafian follicles of the ovary 
has been known to take place before menstruation is established, 
and it may continue after the nK^nopause. The functions of 
menstruation and ovulation are not directly dependent one on the 
other, but both appear to Ix* governed by the same portion of 
the sympathetic nervous system. Cases of precocious menstrua- 
tion are occasionally reported, and it has been known to occur as 
early as a f(»w days after birth. There are many cas(^s on record 
of menstruation at a few weeks or months of age. Development 
of the external genital organs and the breasts, increase in Ixnly 
size, and often the growih of hair on the pul>es goes with precocious 
menstruation. The diagnosis is not established unless the loss 
of blood Recurs at monthly interv^als and a physical examination 
of the child shows evidences of i)remature development. 

It is imusual for m(»nstruation to Ix^ established before the twelfth 
year. On the other hand its appearance is seldom delayed beyond 



MENSTRUATION 



15 



)m. 



the eighteenth year. A case is on record, however, where a woman 
married at thirty-four, menstruated for the first time at forty-five, 
and bore a child at ffirty-.six. According to the invi^stigation of 
I{08si-I)oria, an Italian jihysiclan, who recorded the data in over 
thirty tlionsand women, delayed meni^truation ^ovs hand in Iiand 
with fML*lvic di^ase. He found 39.21 per cent of pelvic malforma- 
tions bi women who had not menstruated until twenty years or 
over. 

The normal rhythm of meni^truation is a lunar month of twenty- 
eight daj's. A woman nmy enjoy perfect health in every respect 
and yet vary many days from the normal rhythm. Many women 
menstruate every three weeks, otiiers every five weeks, with perfect 
rt^pilarity. In getting a history of the menstrual function it is 
nect^<<ary to specify the rhythm of the flow as well as the regularity. 
It is well to rememlx'r alsfj that some women are ix^gular at times 
and irregular at other timet?. 

The duration of the flow i^ from four to seven days. Here also 

variation within normal limits of two days either way is to be 
e<l, TIk' greatest amount of blootl is lost in the first two days. 
A discharge of mucus before and after the How is common. The 
average amount of |j|ood lost at a single mt^nstruation is fi'om four 
to six ounces. It is imprartical>le to measure this exactly and we 
are forced to resort, to the inexact method of counting the number 
of napkins u^mxI. As the napkins vary in size, are used to the 
pouit of saturation by some women and barely stainc><l by others, 
no definite infurmatinn can h» obtained. Intjuiry on these points, 
however, will give the i>hysi(*ian an approximate estimate which 
uld b** rtvonk*<l in detail in his not»'s, Aliout two well-saturated 

pkins a day may lie cdnsiili^red as U^ing normal. 

\Miether menstruation is excessive in any given case depends in 
m certain measure on the physi(]ue uf the patient; a full-blooded, 
plethoric woman may menstruatr right or nine days, using three or 
more well- saturated, large napkins a day; while an aninnicj thin 
woman may be deprinsscnl by the amount of blood lost in a i>eriod 
of four days, using two najikins a ilay. 

The character of the flow is of iini)ni1ance. Note clotting, an 
acid reactibn, a bright arterial color, and any change in odor* 

Attendant disturbances t»f tither functions, iM'fore, during, and 
menstruation, such as nausea, headache, depression of spirits. 



16 INTERPRETATION OF THE CLINICAL HISTORY 

variations in the action of the bowels or bladder, are very commonly 
observed, and should be chronicled. 

Menstruation is generally attended with a greater or less degree 
of a sense of fulness and weight in the region of the pelvis; often- 
times a certain amount of pain is to be considered as not abnormal. 
The menstrual period is a time of instability of the circulation and 
of the nervous system. The body temperature is slightly elevated, 
the thyroid gland is enlarged, and the tonsils and vocal cords may 
be swollen so as slightly to impair the singing voice; so also, in some 
cases, there are salivation and swelling of the mucous membrane 
of the turbinate bones at this time. There is increased vascular 
tension and increased secretion of the s^eat glands and of the 
sebaceous glands, especially those of the external genitals. Some 
women arc affected by skin diseases at their catamenia, notably 
herpes, or small macular ecchjTuoses about the flexures of the 
elbows or knees. 

A rhythmical wave of all the physiological processes has been 
demonstrated by Von Ott. The greatest activity is manifest just 
before the appearance of the flow, showTi by increase of muscular 
strength, tendon reflexes, lung capacity, and heat production. The 
least activity is during the flow, the lowest point Ijeing reached on 
the fourth day. There is a slight reaction in the week following the 
cessation of the flow, an intermenstrual equilibrium of two or three 
days, to be followed by a gradual rise to a maximum two days be- 
fore the next flow, and so on from month to month. 

The Mefio pause. —The climacteric or cessation of the flow usually 
occurs from the forty-fifth to the fiftieth year, the discharge at 
this time becoming less and less in amount and of irregular occur- 
rence, gradually stopping altogether in from six months to two 
years. Menstruation may stop short without any period of irregu- 
larity and there may be no disturbance of the ner\^ous system, 
although the latter is more common. 

If a woman begins to menstruate early the menopause is apt to 
be late, and vice versa. It is a family characteristic sometimes to 
have the menopause early or late. In cas(» of fibroid tumors of the 
uterus the menopause is commonly delayed until the fiftieth year 
or later, and in subinvolution and chronic metritis the menopause 
comes late. 

Vasomotor disturbances are to be looked for during the meno- 



MENSTRUATION 



17 



pause. The monthly rh jlhm which hss existed since the fourteenth 
year ia to be done away with, the sexual organs are to atrophy and 
bec*onie funetionless* If the woman Is in perfect health we shall 
cpect nature to aeeompUsh the ehange gradually an it was estab- 
shed, and withotit an upsetting of the general health. Too often, 
for one reason or another, the health is not rugged, then ensue hot 
flashes, sweating, palpitation, headaches^ nervous irritability, and 
derangements of function in many organs, more especially those 
most closely controlletl by the sympathetic nerv'ous system. 

It is a n)istake to consider uterine hemorrhage as a part of the 
normal menopause. It seklom occurs unless there is a definite local 
cause in the shajx* of a fibroid tumor, a cancer, chronic subinvolu- 
tion with hyperplastic endometritis, misplacenient of the uterus, 
or other lesion. Thc^se uterine diseases may have eauscil no symp- 
toms, though existent for many years. Search should always be 
made for them. 

The Atrophic Changes in the Genital Organs and the Body Altera- 
turns of Uw Men4}pause, — The changes in the genital organs and in 
the body consist of ia) shrinking of the uterus in size. The nms- 
cular tissue becomes less thick and gradually the uterine cavity is 
shortenf*il or even obliterateil, the mucosa IxToming thinnest and 
3e glands reduced in nurnbi»r. Tlie epithelial cells grow smaller 
ftd lo^ their cilia. The vaginal portion of the cervix shrinks and 
dots not project into the vagina, ih) The vagina is shortened and 
narroweil and its walls lose their elasticity and the mucous mem- 
brane its rugae, (c) The ovarirs siirink to sniall knobs of fibrous 
tii^ue, the Graafian follicles disappear, and the Fallopian tubes 
l»*.*come mere cords, (d) The fat disai^iw^ai-s from the \iilva, the 
labia majora become flabby, and the mons veneris loses its prom- 
ioeoee. (c) The pubic hair turns gray after the hair of the head 
has lost iij^ colon (/) The breasts also atrophy and become flabby, 
and iQ) the Ixniy weight is increased. 

Tlic menstrual flow may cease prematurely at an early age, even 
B» eariy as the twenty-fourth year, the causes being general or kwal. 
As Uy the general causes not much is known bt^yond that they have 
to do irith the nutritive and vascular systems. 

The local causi's an^ disea!*L\s which destroy tlie ovaries, as chronic 
infective inflammation, anti removal of the o varices by oiK^ation. 
It is worthy of Remark that when functionating ovaries have been 

2 



18 INTERPRETATIOX OF THE CLINICAL HISTORY 

removed the distressing nervous symptoms of the climacteric are 
much more severe than when the menopause occurs with the 
ovaries in place. (The menopause is discussed fully in Chapter 
XXIX.) 

Vagmal Discharge. — ^Any discharge from the vulva is popularly 
referred to as leucorrhea or whites. A certain amount of moisture 
is normal and is made up of the secretions of the sebaceous and 
sweat glands of the \'ulva, the lubricating mucus secreted by the 
glands of Bartholin Ijnng m the posterior portion of the labia majora, 
— most active during times of sexual excitement, — and by the 
secretions of the uterus. 

The vagina has no secretion proper and no glands, the vaginal 
secretion, scM*alled, being that {X)ured out of the uterus together 
with epithelium and bacteria made acid by a bacterium which 
flourishes in the vagina under normal conditions. The fluid is 
milky and small in amount. The secretion from the cer\ax is 
tenacious, transparent, and thick: that from the endometrium of 
the uterine ca\ity is clear, transparent, and thin. Both have an 
alkaline reaction. 

Skene's glands at the orifice of the urethra also secrete a mucus, 
which Ls thought to protect the meatus urinarius during coitus. 
Under normal conditions the combined discharge should not soil 
the clothing except just before and just after the menstrual 
periods, when all the secretions are increased in amount and may 
necessitate wearing a napkin. 

Abnormal constituents of the vaginal discharge, such as pus or 
blood, should be noted, also a bad odor or irritating qualities. (This 
subject is discussed at greater length in Chapter X., page 143.) 

Pain. — Pain in gynecological affections is generally situated in 
the inguinal and lumbro-sacral regions. 

Backache. — Backache is not characteristic of any special uterine 
disease and it may have no relation at all to the pelvic contents. 
All we can say is that it is very often present in women suffering 
with gynecological diseases. Backache is very common in women 
between the ages of thirty and fifty who are in a nervously run- 
down condition. One sort of backache due to sacro-iliac sub- 
luxation as described by Joel E. Goklthwait (Boston Med. and 
Surg, Journal, 1905, \'ol. 152, 593) must be differentiated from 
rheumatism of the muscles in the lumbo-sacral regions. The sacro- 



PAIN 



19 



I 



I 



■ it 



iliac articulations are true joints and there is inereased mobility 
in them as well as in the symphysis pul>i8 in women during preg- 
nancy and during menstruation. In certain women, espoeially 
thosic ha\ing spinal em*vature who are the \it'tims of subliLxation, 
only one sacro-iliae joint is tender to pressure, and the displace- 
ment is the cause of l>ackaehe as well as referred pains in the hip, 
leg, and ankle on the same side as the loose joints caused by 
pressme on the sciatic nerv^e. These symptoms am not limitM to 
the time of pregnancy and labor, tliough exaggerated tlien. The 
symphysis pubis is generally a loose joint also in these cases and 
may be painful to the touch, especially < luring menstraation. The 
mobility and tenderness of all tliree joints shoulii be tested in any 
ease of bac*kache. 

Mw'icular rheumatism is detected by tenderness on pressure of 
the following muscles: — the erector spinie, — the longissiruiLS,^ 
the E^acro-lumhalia, or the quadratus,^and by pain caiisi»d by the 
tiise of any of these muscles. When a patient with Imn bo-sacral 
rheumatism startjs to straighten up, there is great i)ain, which 
aijates after a few niinytes* ysr-. A [>atient with thisaffcxvtion sits 
or Men preferably with the bod}* bent forward. 

Coccyijodymn is a painful aff^rtion of the coccyx and is charac- 
terized by pain Ix'tween the folds of the buttocks and by tenderness 
on pressurt* applietl to the tip of the cocx'yx. (See jiage 159,) 

Pain in the grains m common in uterine dist»ases. In acute 
inflammation it is generally j»ronniurced. es[iefialty wlirji the 
eum is involved. In chronic uterine dis^'ase it may, or it 
may not, be presi»nt. If existent it is generally a dull, continuous 
pain. If on the right side it is to be cUfferentiated from the sharp 
micrmittent pain of appendicitis, and the pain and tenderness on 
deep pressure in this situation, in cases of uterine disease, are, as a 
rule, lower down than in apiDendicitis. 

4 ftearing-dovm feeling, or o sense of umfjht In the jH'hns, is a very 
fretjuent complaint. If, in answer to your question, the |>atient 
states that she has pa'm, ascertain where it is situated; thc^ point 

greatest intensity; whether it is constant or intermittent, fixed 
tir rafliating; what sort of a pain, dull, sharp, or stabbing. Describe 
it in the patient's own words as far as possiI>le. The relation be- 
tWfCQ the pain and menstruation, if any, shoulii l>e inquired into; 
ilso the rffect of exercise. The situation of the pain often shows 





20 INTERPRETATION OF THE CLINICAL HISTORY 

the nature of the lesion. Thus, pain in the sacral region may mean 
rectal disease, and pain above the pubes, disease of the bladder. 
This is not always the case, as is shown by the fact that disease of 
one ovary is often referred to the opposite side of the abdomen, 
therefore we must be on the lookout for referred pain. 

Abdominal swelling, indicating a tumor of any sort, is to be asked 
for. If present, when was it first noticed, — what is its exact situa- 
tion, — has it increased in size since it was first detected, and if so 
how much and how fast, — whether or no there has been pain in the 
swelling or tenderness on pressure. 

In the case of a suspected ovarian tumor, ask whether there has 
been a loss of flesh about the chest and shoulders coincident with 
the increase in the size of the abdomen. The occurrence of jaundice 
in connection with a tumor in the upper abdomen, as indicating 
disease of the liver or gall-bladder, is to be noted, also the relation 
between a tumor in the flank and impaired function of the kidneys, 
I)ointing toward tumor of the kidney. 

A swelling of the abdomen in a woman of child-bearing age may 
mean pregnancy, however improbable such a diagnosis may seem, 
— therefore ask always the date of the last menstruation. Bear 
pregnancy in mind even if the probable diagnosis is fibroid, 
ovarian cyst, or other tumor; pregnancy, intra- or extrauterine, 
may coexist as a complicating condition. It has happened 
several times in the author's experience that a surgeon of high 
reputation has discovered pregnancy in the course of an abdom- 
inal operation, undertaken for "abdominal tumor" without a 
more exact diagnosis. 

Bladder Symptoms. — The fact should be borne in mind that 
women, as a rule, urinate at less frecjuent intervals than men. In 
obtaining a history it is important to inquire as to the patient's 
habit as regards micturition, lx.»fore drawing conclusions as to the 
abnormality of the symptoms. The occurrence of bladder affec- 
tions is rarer in women than in men. 

Freciuency of urination on standing or exertion, with inability 
to holtl the urine, may mean a stone in the bladder, whereas constant 
dei?ire to urinate may l>e due to cystitis or urethritis; therefore it is 
necessary to inquire* whothcT the frecjuency is by day or by night. 
Smarting on urination indicates some irritation of the vulva or 
urethra. Inability to control the urine at all shows a fistula from 



THE BOWEIiJ 



21 



I 



the hlatldcr into i\w vagina, viihvr rlircc*tl>% or by way of the uterus; 
f fK>wer over the bladder on laughing, sneezing, and coughing 
means lack of su|>i>ort to l)!adder or urethra from injury to the 
fX'lvie floor or to the anterior vaginal wall These* are .samples of 
the class of facts which should b** h^amed. (The subject is con- 

f^dertn:! at length in Chapter X,, page 151.) Ask: — How <rften the 
patient urinates? How freciuently at night? How much ymin in 
the act? When the pain is most intense? How long the |)aiii 
laM*^? Is it possible to control the urine when the desire to urinate 
<x*curs? Is the trouble getting better in- worse? Is it affectvHl by 
meni^niation? Is it Ix'tter or worse when the l>owels are free? 
Wlien did the liifficuhy ix^gin? What is the supixjsable cause? Is 
the trouble the same now as at the beginning? WTiat treatment, if 
y, has lMx»n ustni? 

The Bowels* — Constipation is the rule in a large proportion of 
women suffering with gynecological affections. At least a third of 
all such patients are so affected, according to reliable statistics. The 
statement, however, that a woman is constipated does not descrilx* 
the condition with sufficient minuteness. Many women pay little 

]^tention to their lx)wels^ considering ilefecation as a troublesome 
fimctioQ to be disregardtnl a.s long as |>ossible. Therefore, it is 
neceflsary to make careful iniiuiries to deterniine tliat constipation 
really exists. The amount of ft*cal matter passed depends, of course, 
on the amount and character of frnxl ingested. People of irregular 
habits as regarris their fooil shoul<l Ix^ expectetl to }>ass a variable 
amount of fecal matter; four to eight ounces is said to be the 
normal amount passcnl in twenty-four hours if the patient is Ii\ing 
on a mixed (Het. The amount is more if the diet is vegetable rather 
than if animal. Habits of a lifetime have a controlling influence on 
defecation, and a person may evacuate the bowels regularly every 
other day or twice a tlay and yet Ix* within the limits of the normal. 
We must inquire whether the bowels move regularly, i\€\, without 
raetlicine, enema, or artificial aid of any kind, at statcM:! periods of 
time, and what those times are: whethei* th<* action is full, or 
ty, and the stools solid, semisolid, or liquid: whether there is 

^fiajii on defecation at the time (hemorrhoids) or lasting after the 
mo^x^ment (fissure of the anus); whether the stools am ribbon- 
like (iftricture of the i^ctum); whether offensive (decomposition); 
containing blooti, mucu*s, or pus (hemorrhoids or fistula in ano); 





22 INTERPRETATION OF THE CLINICAL HISTORY 

whether there is escape of gas involuntarily (some injury of the 
sphincter, or fistula in ano). 

In some cases of injury of the pelvic floor the patient finds that 
the only way she can evacuate the rectum is by making digital 
pressure in the vagina. Prolapse of the rectum on straining at 
stool is to be borne in mind in getting the history. 

Inquiry should be made as to the length of time constipation has 
existed, whether it is habitual or intermittent, and whether, in the 
patient's mind, there is any assignable cause. The physician should 
consider a pelvic tumor, rupture of the pelvic floor, a stricture, or 
malignant disease of the intestine as possible causes of constipation. 
(See Chapter X., page 156.) 

Present Illness. — Under this heading we group together the 
symptoms whi(»h go to make up the complaint for which the patient 
consults the physirirfn. They consist of the data as to the functions 
of the different organs. Aj)petite, digestion, and sleep receive con- 
sideration in the detail justified by their importance in any given 
case, also any symptoms indicating derangement of the heart, 
lungs, kidneys, or other organs. 

\'ariations in the body w(^ight are important as showing changes 
in the nutrition. Other things bcnng e(iual, a greater weight shows 
increased vigor and strength; such a statement being susceptible 
of modification in the case of very fat people. 

In this portion of the history the physician has an opportunity 
to show his ability as an internist and by his knowledge of the 
science and art of medicine^ to ke(»p his patient, if passible, on the 
main line of practice instead of shunting her on to the sidetrack of 
sp<»cialism. 

It is always wise to note the* exact date of the last menstruation 
before finishing the history. A habit of doing this will go a long 
way toward preventing awkward mistakes. 

Finally, as a matter of record, make a memorandum of the 
patient's peculiarities of form and figure. 




CHAPTER IV 



THE PHYSICAL EXAMINATION 



r The preparation of the pnfient* p. ^. 

II. The preparation of the examining table, p, 520. Cure of the instni- 
ments. with list of a full kit, p, ^H. 

III. The examination: 1. Preparation of the physician tmd plaein^ the 
patient on the table, p. 31; The dor$;al (Kisitiiin, p. :13. ^. fn!!»p*xlioti of 
llie e%temaJ genilalH, p. S3. S. I'aljjiition. p. 114: (a) Ttie vaginal touch, 
p. $4; (h) The (x>mbined vaginal and atxluminal touch, p> tin. 

Having taken the histon' as outlined in the prccetling chapter, 
the next prwetluir is the physical examination. It is nut neees- 
Hary to follow exactly the same routine^ in ul! eases: iievertheleHs 
it y mottt et^eential to have a definite' syslein ami tt» [inH't^nl areonl- 
tng to it in all but exceptional instances. iK^cause in this way, and 
in thi^ way only, are Rvurces of error^ the oniissinn of important 
9tgns, reduced to a mininiunj. 

Firj:t let us consitler L the pre/ttiratif^n of the jKitimt, then IL the 
preparatitm of the examininff tahle and the instrumvnt^, and lastly 
HI. the examination itself. 

So much does a go«>d diagnosis depend on careful preliminaries 
and on a nmltitude of little things that no apology is necessary for 
the space <levote<l to them. 



L THE PREPARATION OF THE PATIENT 

It is absolutely essential that the rectum should be empty in 
nnler thai the |>hysician may make a satisfactory bimanual ex- 
aniination, also, in the ca*^ of alKiominal [>alpation. if the Ix^vels 
are distendtn:! by feces or gas the ability of the examiner to appn- 
ciate the condition of the alxlominal contents will l^e interfeix*il 
with. Then^fon* the (mtient, if there is inY'd and if time serves, 
HhouJd Ix* instructs! to take a catharlie thi^ day before the exam- 
ination or an enema immediately lx»foi-e, 

23 



24 PHYSICAL EXAMINATION 

If a patient presents herself with the statement that the 
bowels have not moved for several days it is better not to 
make an examination until they are solvent, except in cases of 
emergency. 

Unless there is some suspicion of disease of the urinary organs 
the bladder is to be emptied just before the examination. In 
certain urinary cases, where it is desired to obtain a catheter speci- 
men of urine at the examination, the patient should be asked not 
to empty her bladder before the examination. 

As a rule it is better to have no douche or special wash given 
before the examination, because the examiner wishes to form an 
opinion as to the character of the discharge, if present. It is a 
simple matter for him to wipe away the discharge later with sterile 
cotton or some antiseptic solution. 

The most important matter in connection with the preparatory 
treatment of the patient and the one most often overlooked is the 
loosening of all constricting clothing about the waist. Simply to 
loosen the corsets and leave the drawers buttoned about the waist 
is not sufficient. So often women come to the examining table 
with corsets and skirts loosened, and investigation reveals one or 
two tight, constricting bands still left. Closed drawers should be 
removed. The union suit is a foe to an accurate diagnosis and 
should be removed. If the patient considers her condition of 
ill health important enough to consult a physician she should be 
ready to offer no hindrance to a proper examination. 

With any encircling girdle about the upper abdomen it is mani- 
festly impossible to compress the abdominal walls and to palpate 
the contents of the abdomen and pelvis. Such palpation is difficult 
enough with all conditions favorable, therefore do not handicap 
it by omitting to have all clothing loosened. 

If the patient is in bed she should be prepared by having her 
put on a fresh pair of stockings. Should the Sims position be 
used an extra towel will serve for covering the right thigh. 

Much depends on the physician's tact and the manner in which 
he goes about the preparation for the physical investigation. 
Women do not mind an examination which they consider necessary 
if the physician shows proper consideration for their feelings and 
knows how to go about the examination. If the matter is treated 
as disagreeable and to Ije put through as quickly as possible, the 



PREPARATION OF THE PATIENT 



25 



I 



I 



» 



result is apt to be that th*^ |i]iyj*ieian's framr of uhikI will Ir rc- 
flwttil in thf patient and slic will tx^ ill at viisi* and consequently 
will not give herself up to the investigation^ not relaxing the al> 
(ioniiual muscles and thus limiting tlie fai'ts which may be gleauetl 
through the tactile sense. 

The patient shoulil lx» made to fei*l that the examination is to 
be conducted with as little pain and discomfort as is possible* and 
thai this is an imixirtant consideration to the exaoiiner. 8he may 
be told a fact too often lost sight of, that pain^ caused by roughness 
or vigorous handlings makes unconscious resistance and rigidity 
of the abdominal nmscles, then^by dulling the sense of touch in 
the doctor's liands antl jjreventing him from reaching dee{>lying 
f?tructur€?s— conseciuently the examination is less successful. 
Often it is inatlvisable to make a thoroiif^h hivestigation and a 
complete diagnosis at one sitting. Sometimes if is necessary to 
examine the patient on several <hfferent ot^casions before all the 
conditions have been fomid favorable anil all the facts have been 
brought out. Therefore do not be Ird to express an opinion on 
the ease prematurely. 

In the ca^c* of young girls it is generally mlvisable to use an 
anes^thetic before making a kx-al examination, although it is not 
always nt*ceasar>% nmch depending on the nervous temjx'rament 
of the [latient. In making an examination of a virgin in whom 
menstruation has bc*en establish wl an anesthetic is seldom requued 
if gn^at tact ami gentlen(*ss are used. It is far pref(i*able to make 
the first exaniination without ether if possilile, bx*ause often facts 
ot importance, such as regions of tenderness, brought out during 
the examination, are lost in an ether examination, to say nothing 
of the unfavorable after-effects of the anesthetic on the patient. 
Should the first investigation show the need, another examination 
with ether can Ix* made. 

Too much can not Ix^ said of the importance of the tactful hand- 
ling of the patient prr^vions to the examination. To see one skilled 
nurse in a large hospital clinic put forty women on the table for 
examination during the course of an afternoon, no complaints, no 
nbjeetions, and one following the other with military prwision, 
iif an object lesson of no mean value. Few nursc^s accjuire such 
experlnnsH, and to few is it neeilful. Much may be leamal by 
\ying, when the opportunity offers, the way it is done. 




26 PHYSICAL EXAMINATION 

The local examination should be made during the intermenstrual 
period. Only in the case of hemorrhage and unusual conditions 
is it necessary to examine during menstruation. 



II. THE PREPARATION OF THE EXAMINING TABLE AND 
THE INSTRUMENTS 

Some hard surface on which the patient is to lie is a necessity 
for a proper examination. A soft bed or couch into which she 
sinks takes away all space imder the buttocks for the unused fingers 
of the examiner's hand in the vaginal examination. Besides, most 
bcKls and couch(»s are so low that the physician is in an uncom- 
fortable position while examining and so many of his muscles are 
tense that he can not concentrate his entire attention on what his 
fingers are feeling. Furthermore, with the patient on a low couch 
the physician cannot get his eyes on a low enough level to look into 
the vagina unless he sits on the floor in an awkward and constrained 
position. 

A tabl(^, the size, shape, and height of an ordinary kitchen table, 
is on the whole the best surface on which to put the patient. Port- 
able or fixed supports for the feet are a useful addition and also a 
movable slide projecting from the right-hand lower comer of the 
table is a convenient adjunct. My table is stoutly built of walnut, 
has large casters on all four feet, and is of the following dimensions: 
— Length, 44 inches; breadth, 24 inches; height at bottom end, 
33 inches; height at head end, 31 inches. 

It is to be not(Hl that th(» foot or examining end is higher than 
the head end. This is to cause the viscera to gravitate away from 
the pelvis and to allow of more pillows for the head without in- 
clining the trunk downward toward the pelvis. 

The table is covered with a hair pillow one inch thick, encased 
in a dark-colored, enamekHl canvas cov(t. This cover is buttoned 
to the under edge of the table top, as the removable sides of a 
carrijige are fastened on. 

Fixed or portable rests for the feet are an advantage, because 
with the fe(»t slightly el(»vat(»d above* the surface of the table and 
at a short distance IxTond th(» table's edge the alMlominal muscles 
are more thoroughly n^laxed and the i)atient is more comfortable 



PREPAR.\TION OF TABLE AND INSTRUMENTS 27 

than she is with heels clo^ to the buttocks, and slipping off the 
table. 

In private houses the kitchen table is always availablo or, if it 
is best in occasional instances to examine the patient, in bed, an 
ironing board or bread board may be placed on the mattress under 
the patient's hip8, which shoidd be at the etlge of the lM?dj the feet 
resting in two chairs. A foklod blanket, or two thicknesses of a 
comforter, should be laid on the table or board to take away tlie 
hardness. In this way the jmtient is reasonably com f nil able during 



FiQ, h— The Exuniimng Table. 

tbe nhort time occupieil by the examination and the physician can 
do his work to the best advantage. 
There are few points of superiority and many rlisadvantages 
the compticatf»<l and costly tablc^s sold in the instrument shops, 
patient is not at ease on an unstable surface antl she does not 
Dke to feel that by the pressure of levers she may be tilted into all 
8Drtj9 of positions; she is not in a state of mind to appreciate tlie 
beauty of the ingenious mechanLsm concealeil in the table, aud 
would rather lie on a solid, warm wooden table than on a hard, 
one, made of glass and iron. 



^ 



28 PHYSICAL EXAMINATION 

The ordinary vaginal examination need not Ix) a strictly aseptic 
operation, and it calls for clean, not aseptic furniture. 

Suppose we have the table placed with its end toward a good 
light. We cover it with a folded comforter and a sheet, unless it 
is already provided with a permanent cushion. When the patient 
lies on her back with hips and heels at the edge, the only portion 
of the table which will come in contact with the region about the 
vulva and anus is a narrow part of the middle of the end, some 
two inches wide and six inches long. Therefore for every patient 
a fresh towel is opened just as it comes from the laundry and a 
newspaper is folded into it so that the original folds of the towel 
are reproduced. This towel, about six inches wide and a foot 
long, is now placed in the middle of the examining end of the 
table and one end tucked under the comforter or cushion. The 
surface to sit upon is thus some six by nine inches, according to 
the size of the towel. In this way each patient sits on an abso- 
lutely frash towel, and the table is protected from the vaginal 
discharges or solutions used by the physician, by the newspaper 
which has been folded into the towel. 

It is seldom necessary to soil the sheet or cushion. If by any 
chance it is soiled, as in case of hemorrhage, the sheet or towel 
is removed and the enameled canvas surface of the cushion is 
washed and a fresh sheet or towel put on. A pillow for the pa- 
tient's head is placed at the head end of the table. 

Care of the Instruments 

X'^ery few instruments are necessary for the routine gynecological 
examination. A uterine dressing forceps, a sound, and a small- 
sized bivalve speculum are frequently all that will be requu-ed. 

It is best to keep all instruments out of the patient's sight, 
because she does not admire them nor look at them from the same 
point of view as the doctor, and it is not at all reassuring to feel that 
all the bright instruments of seeming torture may be used on her. 

My full kit contains the following instruments: 

Flexible uterine sound; 

Uterine probe; 

Bozeman uterine dressing forceps; 

Uterine tenaculum, single; 



rUEPARATIOX OF TABLE AND IN8T1U MENTS 



29 



Uti*rine trnaculuin, iloublc, or vubclluin; 

Uterine gicis^ors; 

SilvcT ukTiiif* [iroJx' : 

Small-size Brewer bivalve speculum ; 

Graves bivalve speculum; 

Smallest size Sims 8|>eeukmi, al^o No. 4 size: 

Eklebohls s{>eeulum (ineludeti in the kit for eases in which 
euretting or removal of a piece of tissue is nece^^stu-y for diagnosis ) ; 

Hunter vaginal depressor; 

Emmet curette forceps; 

Bozenmn-Frits(^h uterine douche; 

Two uterine applicators; 

Uterine sharp curette with flexible shaft; 

Set of Hanks metal uterine dilators; 

Warthen uterine dilator; 

Silver female catheter; 

Kelly meatus calibrator: 

Set of KelJy double-endetl steel uretliral sounds; 

Kelly cystoseopes, Nos. S, 10, 12; 

Alligator bladiler forceps; 

Two Kelly ureteral catheters; 

Kelly proetojicoixNs, two sizes; 

Kelly ureteral searcher, and rubber bulb and tube for suction; 

HeaiJ mirror; 

Stethoscope; 

Pelii meter. 

Added to these are: 

Two sterile two-ounce l»ottles; 

Compressed tablets of cocaine hydrochlorate; 

Sterile absorbent cotton ; 

Sterile gauze; 

A bottle of creolin: 

Cover gla.s?«es. 

A collajieible tube of a sterile, soluble lubricant sold under tlie 
names of Lubrichondrin, Glycerine Emollient, Muco^ or K-Y 
Jelly. 



It is my practice to have one set of instruments in a drawer 
within easy reach of niy right hand as I sit in front of my examin- 



30 PHYSICAL EXAMINATION 

ing table; another set is in a bag ready to be carried to consulta- 
tions at the patients' homes. 

After use the instruments are scrubbed with soap, hot water, and 
a nail brush, rinsed with boiling water, dried at once, and put away 
clean. In cancer cases and those in which infectious matter is 
pretty surely present the instruments are boiled in soda as well as 
scrubbed with soap and water before bemg put away. Before use, 
the instruments which it is thought will be used, are placed in a 
shallow enameled iron tray and boiled for five minutes in a one- 
per-cent solution of washing soda in water; the soda solution is then 
poured off and hot water substituted. No instruments are ever let 
lie for any length of time after use without being washed. Until 
cleansed they are always kept immersed in water so that discharges 
and blood can not dry on. 



III. THE EXAMINATION 

1. Preparation of the physician and placing the patient on the 
table. 

2. Inspection of the external genitals. 

3. Palpation: (a) The vaginal touch. Dorsal position. 

(6) The combined bimanual vaginal and abdom- 
inal touch, including points in the anatomy 
and the findings on palpation. 

(c) The rectal touch. 

(d) The bimanual recto-abdominal touch. 

(e) Positions of the patient used in gynecological 

examinations other than the dorsal; the 
Sims position; the knee-chest position; the 
lithotomy position; the raised pelvis posi- 
tion; the standing position. 

4. Odor as a diagnostic sign. 

5. The collection of the discharges and tissues for bacteriological 
examination. 

6. Inspection of the abdomen. 

7. Palpation of th(» alxlomen. 

8. Percussion, auscultation, and mensuration of the abdomen. 

9. Instruments and their use in diagnosis. 



THE KXAMIXATION 



31 



L Preparahom of the Physician and Pu^cino the Patient 

ON THE Table 



The physician preparers himself by washing his hainJs 
carefully and if they are cold by warmmg thcni, and by 
pulling up- the sleeves of his coat and hLs cuJTs so that they 
will not come in contact with tiie patient. As to rul>f>t*r cots 
and rubber gloves, they interfere with the tactile sense, how- 
ever used, and should l^e employed only in exceptional in- 
stances, as in cases of suspected gonorrhea and of ft^tid dis- 
charge, also in rectal examinations. They serve to protect 



huv 



i ..iininirig IIlhiiI, iShowing rmU-ftive Sleeve, 



fsoming patienta and also the physician from contamination, as 
mocuUtion with syjihilis, and favor the cause of asepsis. The 
physician who is personally neat anil washes his hands care- 
fully Ix^fore as well as after a vaguial examination ^ need have 
no fear of carrying bacteria from [latic^nt to patient. The 
exanuiiation can not be so well made with cots or gloves as without 
them^ therefore do not ust* them unless necessar>^ 

As to protecting the slei*ves, it is a grnid jjlan to worn' sleeves 
niftde of "Stork sheeting" or thin rubber, with elastics at 
the \%Tista and elbows, pullnl tm tner the coat skives. These 
rubber sleeve^t can be freijuently cleanscMl and they prevent 
eairying inf(X'tion from anv patient to another. They ot>viate 
tbc ncccsrfty of removing the coat, a procedure which is undesir- 



32 



PHYSICAL EX.\M1NATI0N 



able bpcause it seems to intlicate to the patient formidable mi- 
(iriiakings. 

Of the iniportanre of washing the* haiuls iK'fnre th(^ examination 
too much can not he said. Oni* never knows what Imcteria he 
may have on his hantls and under his finger nails. Every one 
necessarily washes hh Irnnds after the examination; how much 
more essential, from the standpoint of the patient's safety, h the 
preliminary wash. He who woulii [jraetice gynecology must ha\*e 
the handwashing habit. 

It is my custom to prepare a Imsin full of w^arm creolin solution, 



one i>er cent,. and place it on the instrument table within reach of 
my right hand. As lx*fore stated, the examination is not and ncn^d 
not Ik* a strictly ase|)tic operation; tliercf ore some antiseptic, w'hieh 
does not coagulate the allnnjjen of thi! discharges, has an odor of 
its own, does not corrode instriunrnts, nor irritate the tissues, is 
indicated. Any talJe will serve on which to lay the pan of instru- 
numts, Imsin, and sttTik* cotton, A low table is preferable to a 
high one. Its surface should te covert^d with a fresh toweh 
The usual position employed in gynecological examinations is 




INSPECTION OF EXTERNAL GENITALS 



33 



_ hini 



the (loi^tal position. The Sims position, the knet^ehest position, 
the elevated pi^lvis po^^ition, the hthotomy position^ aud the stand- 
ing position wiU \je <Jescribed later* 

The Dorsal Position, — Evenlhing lieing in readini'ss, the patient 
ste(j8 into a hani-bottomed ehair placed at the foot of the tal>lc 
and raiises all her skirts Ijehind, the physician meanwhile f^tanding 
in fmnt of her anti holding up a yheet, so that she is screened from 
hini as ^he sits on the little folded towel on the edge of the table. 
She lies do^ii antl puts her feet in the supports. To prevent 
hiing the bwck it is well to a^sk the patient to draw up her knees 
B she lies dowTi, othen^xsp fier back will reach the cushion while 
her feet are still in the ehair, putting her into a sort of WalchtT 
position, one of great diseonifort. 

The sheet is now thrown over the nTiinilx^nt w^mian so tliat 
she is entirely eovvreiL Holding the lower nige of the sheet in 
the h'ft hand the ph>Vieian raises the patient's skirts in front with 
his right hand under the sheet. Then by carrying the middle point 
of the sheet U))ward to tlie pu!ne rt*gion both thighs are ilrape<l and 
only the vulva and anal regions are e\p{>se<L A woman does not 
object to an exposure of the genitals that is nianifestly necessary 
!*o long as the surrounding parts and the body are covered up. 
This method of coverifig with theshtvt is aj)plieable to every sort 

Eof a ea*H% and shoukl be enijiloyed always unless the patient is 
kie5tbetize<l 
If the examination is at the patientV lionn' tlie tablf* is (prepared 
in a gooil light in her nx»m and she eithrr walks to the examining 
t^bie, Of, if unabk' to walk, is carried from the bed. 



2. LvSPKiTION OF THE EXTKKNAL <5kMTAL8 



There is no valid objection to an inspection of the vulvar region; 
in fact, a pri>iHT <liagnosis can not Ix' nmd<* without it. The iihysi- 
cian sweats hinus<»lf m the chair uschI by the patient to get upon the 
table, atid spreads a fresh towel over hb knees. By placing the 
fingers of eaeh hand on the labia majora the labia are drawn gently 
mut^il he notes the condition of the hymtm, whether with one 
•wOHwoi>enings, unbmken or ljrokf*n; the amount and charaeter 
of the vaginal tiisoliarge; the ap|>earance of redness alx)ut the 
orifie(*s$ of Bartholin's glands or Skene's glanrls. 



34 PHYSICAL EXAMINATION 

If redness appears about the orifices of Skene^s glands, the well- 
anointed finger should be introduced for an inch into the vagina, 
pressing backward toward the sacrum with the dorsum of the 
finger as it is slipped into the vagina, and gentle pressure made 
with the tip of the finger along the course of the urethra from 
above downward to express pus from the glands. 

He notes further the condition of the meatus urinarius, whether 
closed or open ; the prepuce, whether adherent to the glans clitoridis 
or not, and injuries of the perineum. The surface of the perineum 
between the fourchette and the anus shoukl present a convexity; 
if it is flat or concave it means an injury to the pelvic floor or 
perineum. 

Palpation is to Ix^ combined with inspection in determining the 
nature and extent of injuries in this region. (See Chapter XX, 
page 372.) One must be on the lookout for skin affections. Pedi- 
culi are occasionally found among the poorer classes; and all sorts 
of anomalies of the external genitalia are to be looked for. In- 
spection of the vagina will be taken up in the chapter on the use 
of instruments. 

3. Palpation 

Palpation includes the vaginal touch, the combined bimanual 
vaginal and alxlominal touch, the rectal touch, and the combined 
bimanual recto-abdominal touch. The examination of the abdo- 
men will be considered in another chapter. 

(a) The Vaginal Touch. — The physician has washed his hands 
with care, his nails are always trimmed short and are clean, and 
his hands are warm. He stands facing the patient, who is in the 
dorsal position on the examining table. Now comes the question 
which hand to use for the vagina. I prefer the left hand for the 
reasons that the left hand is less frequently usc^d for ordinary pur- 
pos(\s than the right; therefore, the skin covering the terminal 
phalanx of the left fon^finger is softer and capable of higher training 
of the tactile sense; less strength is required of the examining 
hand at the vagina than of the hand on the abdomen, which is 
engaged in gross manipulations, the right hand is usually the 
stronger except in the case of left-handed persons; the left hand 
is generally a trifle more flexible than the right hand, an important 



I 



PALPATION 



35 



I 



uu- 
■ du 



I 



consideration with reference to stowing away the unused fmgens, 
and finaJJy, usbig the left finger for the examination leaves free the 
highly trained right Imnd for the delieate manipulation of instru- 
ments. 

Whichever finger is chosen, that ont* should be used in alt but 
unuKual cases, Ix^eause it is desirable to educate one finger to fwl 
correctly. It is the exceptional physician who can become ambi- 
dextrous* 

Having decided on the left forefinger, it should be lubricated 
becauise the external genitals are ilry, and pushing in the external 
parts cau.ses the patient ilisconifort : it is the t?kin which is in need 
of lubrication rather than the vagimi, which is supplieil normally 
with a lubricating medium, then:*fore anoint the external labia and 
theses in turn will luljricate the finger. The iMAst hiliricant is some- 
thing of the naturt^ of lubrichondrin, sokl under the name of *' myco- 
lubricans'* or **K-Y/* prepared from cartilage treated with heat, 
a mildly antisejjtic jelly containing eucalyptol or gaultheria, or 
^me other su Instance to give it a pleasant odor. It is soluble in 
wattT* It is kejit in a str rile, coIla[>sible tulx* and is free from all 
danger of contamination. The oils and vaseline are peculiarly ill 
«uited for lubrication Ix^ause they cling to the finger and instru- 
ments and are well adapted to receive, retain, and distributt* juitlio- 
gdiie organisms. Soaps are irritating to many patients, particu- 
larly in inflammatory^ conditions of the external genitals. The 
physician s<jufH'zes fmm the tuU* an ample (juantity of lubri- 
diondrin on to thciiorsal aspect of his forefinger, anointing only the 
temiinal and second jihalanges. By bringing the hand downward 

til the little and ring fingers touch tlie table just under the cleft 
trf the buttocks, the tijj of the anointt^l forefinger seeks the perineum, 
Wlien it is reacheil thc^ back of the IxTit forefinger is drawn upward 
over the fourchette, thus Inbricating the laliia and the vestibule, 
the knuckle falling into the dcjiression at the introitus vaginte, 
A secon*! sweep with the finger, it is straightened, ami the ti|> settles 
into the vagina. It is to be notetl that the luliricant has been put 
rmly wh«»re it is needetl and that there is none on the unused hand 

id on the patient's linen. 
n introflucing the finger into the vagina one bears in mind the 
condition of the hymen as notetl at the previous inspection. If 
the hynien is tight great gentleness should be used and sufficient 



36 PHYSICAL EXAMINATION 

time allowed for dilatation. Room in the vagina is always to be 
gained by pressing backward toward the sacrum, as the perineum 
and pelvic floor are dilatable in this direction only. The structures 
which hug the under surface of the pubic arch, the clitoris, vestibule, 
anterior vaginal wall, and urethra should be avoided as far as 
possible, as in that region sensation is most acute. 

The examining finger may be likened to a small speculum as it 
carries down the perineum and opens the vagina. In many cases 
it is possible to use the finger in the place of a speculum. 

As soon as the middle knuckle of the examining finger has passed 
the hymen the hand is turned so that the thumb is upward. The 
three unused fingers are carried be»hind the anus in the cleft of the 
nat<^s and the thumb is moved to the left or right of the median 
line out of the way of the clitoris. The perineum and pelvic floor 
can be pushed in to a variable extent by the web Ixitween the 
index and middle fingers and thus the examining finger reaches 
farther. It is seldom necessary to employ two fingers for the 
vaginal examination, although there are cases where more may be 
learned with two than with one. The palmar surface of the last 
phalanx of the forefing(»r is the chief seat of the trained tactile 
sense. As a nil(», parficularly in virgins, two fingei"s cause the 
pati(*nt a great deal of discomfort and therefore accentuate the 
disagreeable f(»atures of the exammal^on, t(*nduig to distress of 
mind and body and consequently preventing the relaxation so 
essential for a succ(\ssful investigation of the contents of the pelvis. 
The scope of the vaginal touch (h^pends, in a measure, on the ana- 
tomical pe(*uliarities of the examinee's hand. A physician ha\ang 
thick, chunky hands with short fat fingcTS can not hope to be as 
good a gynecological diagnostician as oiu) havmg a slim hand with 
long, tapering fing(TS. In women of spare build who have borne 
children, practtically the entire inner surface of the pelvic caxity 
may be palpat(^d by a long finger or fingers introduced uito the 
vagina. It is not unusual to touch the promontory of the sacrum 
and the sacro-iliac synchondroses, })esi(les all parts of the fXilvic 
floor, not to mention the structures occupying the pelvis. (See 

Fig. -1.) _ 

The examining finger as it enters the vagina notes the following 
points: — The state of th(^ hymen, whether with large opening or 
small, whether rigid or easily dilatable; the vaginal walls, whether 



PALPATION 



37 



with rugiv or s^iiiootli, wht'thtT of noruial teiiipcratun*, or hot, as 
in the case of inflanimatory aflVt'tioos of the pelvic organs, or in 
fevers; whether the walls of the vagina are in apposition, or lax 
or separatetl; the afnount of swrrtion, a dry vagina gi^^ng an en- 
liR*ly different s4.*nsation from a moist one; the condition of the 
pelvic floor and perineum; in the case of a parous woman sttarch 
for a groove in either suleus or the middle lino, rcmemlx:*ring the 
nornml conformation of the |XTin(nmi, that is to say, a convex 
fiturface in the vagina as well as oti the skin outside; sometimes it 
is wvll to introduce the well-anointed forefinger of the right hand 
in the anus and palfjate the tissue lying lx*tween the tw^o 



■ he I 



Flo. 4. — ^llalf a I'VinaJc Pelvis, with Hand in Position a« /or Vaginal 

Fjxamination* 



:ers in onler to get a cujrreet i<lea as to injuries which may 
be proftciit. The vaginal touch infomis us as to the contents of 
tbc rectum, tvhether emjtty or containing hard fiscal masses, s<»nii- 
8olifi feces, or dilatcnl by fluid or gas; also wliether or no the blad- 
der y fiist^^ndtnl. 

In onler to prmHice this sort of palpation succ(»ssfuUy re- 
quires a long exjjerience and a thorougli familiarity with the 
normal conditions, also the variations of the normal in different 
iiidividtmls. 

Abnormalities of the vagina are to be detected by touch ; such 
am cystis, partial scptujii, narrowmg of the lumen by cicatrices^ 





la,. .J.— Diiignuiimatic Drawmg, Illustnaing thc^ Hiiiuumul Touch, 

flieating tho f^itiiation of ulcerated an^as in the Ijladtler iiiufom. 
Tlie ureterH wlic^ri thiekenrd arc* easily iml|)ablr I'uruiitig from tlie 
bladder bas<^ toward the ^arro-iliae synchondroses. Tho iii>p(T 
eourso of the iielvie j>oHion rjf the ureters can be lx\^t detected by 
reetal examination. 

(h) The Combined Bimanual Vaginal and Abdominal Touch.^ — 
^\Tien the tip of the examining finger reaches Ihe posterior 



PALPATION 



39 



I 



fornix of \hv vaf^ina thr [jhy.sii-iafi's right hand is laid gt-ntly 
on the lower alxlonien, palm ilown willi tlm hri'l of tlip liarul 
]ugt aljove the symphysijis pubis. Very gentle and slowly applied 
pn^*^ure is rriaile with this abdominal hand, all siuiden movement 
bcnng avoi(ksi as calculated to exeite pain and consequently 
reristancc of the alxlominal muscle??. The balls and not the tips 
of the fingers are ust^L The pelvic organs are <-arrie(l down l>y 
the pressure alx)vc until they are witliin reach of the finger in 
lh€* vagina, and conversely they are raised by the fingcn^ Ix^low 
until within touch from ahivc. In the case of the bimanual 
Vftgin<>a^Klominal touch we hf>ld Ijetween our hands (the finger in 
the vagina and the hand on the alj<lom(*n) the contents of a Imx, 
the cavity of the pelvis. 

It is sometimes a help in making th** IjiTnanual examination for 
the physician to rest tlie cibtiw of the hand making tlie vaginal 
iciurh on the knei» of the corn^sponding leg, his f(K>t (x4ng placed 
on the chair which is close to the table. 

Factors outside of the condition of the lx)W"els and rectum 
limiting what can hf felt l>y ttie bimanual toucli are, tlie amount of 
ailipoe«c tissue pn^st^nt, and the rigidity or laxity of the muscles 
of the alj<lominaI walls. A rigid perineum has been n^ferrerl to 
already as lessening the amouTit of invagination of tht^ pelvic floor 
that may Ix* maile l)y the web Ix^tween the fingers of tlie lumd at 
the vulva. 

In fat women lH)th the viiginal and bimanual touch are in- 
ennl with. Other things l>eing e<jual, it is impossible to 
make as accurate* a diagnosis in a fat woman as in a thin woman. 
Tht* fat in the |X'rin**al rc*ginn reduces tht* s(*ope of the vaginal 
touch. A greater hindrance is the fat in the alxlominal walls; 
nith two or three inches of fat in the pannicuhis adiposus the 
die sense is much Wuntcd, It is like feeling ihrougli six or 
light thicknesses of l)lankets. Naturally , th<'n, w(* do not hope 
to make as goo*t a diagnosis as when the abdominal waUs con- 
little fat. 

A rigid al>domen is a Imr to iliagiiosis by touch. One can feel 
it tie through a stiff sheet of past(4)oarfL If there is |>resent 
itis or gn^at sensitiveness of the alwlomen from any cause 
we expect to find rigidity. Many patients become rigifl through 
iety and fear of painful mani|*ulations by the physician, others 



i 



40 PHYSICAL EXAMINATION 

reflexly because of the discomfort caused by the laying on of the 
hands. Therefore, not only is the utmost gentleness imperative, 
but also it is a matter of supreme importance not to arouse the 
patient's fears by brusk behavior, or by the uncalled-for display 
of instruments. 

As to gentleness, the flat hand on the lower abdomen makes 
light pressure and the physician inquires whether it causes 
pain. Distracting the patient's attention by a question or two 
often prevents rigidity. Next, the hand is arched by flexing 
slightly all the fingers so that the balls of the fingers press in 
deeply. It is very essential not to make the tips of the fingers 
press, the same rule holding here as in massage. Make pressure 
with the palmar surface of the last phalanges, for the tips of 
the fingers and the finger nails cause pain, and, also, less can be 
felt with the tips. 

Ask the patient to take a long breath; as she does so, gently hold 
the abdominal wall in. Repeat the process and the examiner's 
hands are brought nearer and nearer together with each expiration. 
Judgment is necessary in performing this maneuver because too 
rapid or too forcible pressure will cause the abdominal muscles to 
contract, thus defeating the objects of the examination. Assist- 
ance is gained in some rare cases by drawing down the cervix 
with a tenaculum lield by an assistant. In this way the back of 
the uterus and the broad ligaments are reached and also tumors 
and other attachm(^nts are made out. 

The bimanual or conjoined examination is the keystone of the 
gynecological diagnostic arch. Nothing takes the place of the 
trained touch, and it is doubtful whether, in the march of progress, 
any form of investigation will supi)lant it. 

Specula for the vagina, the bladder, and the rectum, bacteriology, 
and the microscope with its findings as to the nature of the blood 
and tissues, and the x-rays, detecting a stone in the bladder, 
ureter, or kidney, all have their uses. The bimanual touch is the 
most important. 

The finger in the vagina notes, first, the situation, size, conforma- 
tion, consistency, and sensitiveness of the cervix; lacerations, 
their location and extent ; whether or no the tissues of the cervix 
are of normal consistency, or soft as in septic conditions or after 
labor, or indurated as in chronic metritis. The friable, bleeding 



PALPATION 



41 



» 









cervist iSi^Sicer is rarely mistaken for an 3' other eondition, except 
pogsibly a sloughing, iKHiurieulated hhroid. 

Cysts of the Nabothian follicles can be diagnostieated as 
shot-like bodies; a stringy, tenacious plug of mueus in the os 
can be differentiated from a thin di.^eharge: in rare cases the 
cervix may be out of reach, being forced upward into the abdomen 
by a tmnor in the pelvis so that it may lie on a level with the 
upper l)order of the sjiiiphysis pubis; the different situations of 
Uie cer\ix in the various malpositions and malformations of the 
TUB will be considered in the chapter devoted to these diseases, 

;e long conical cer\ux found espt^eially in jiathologieal ante- 
flexion^ 80 called, is readily distinguished from its opposites, the 
apparently short cervix — one in which the vagina has teen 
stripped by chiltUx^ariog from its attachments to the portio, or 
from the really short senile cervix. 

The pinhole os is differentiat*^! by touch from the os tinea*. 
By the vagmal touch we detect a polypus projfH-ting from the os 
uteri. In the case of large |>olypi we detect the location and size 
of the i>e<:licle by sweeiJing the finger about the tumor anil noting 
where and how it is attaeheil. Sensitiveness of the cervix to light 
pressure indicating endocervicitis is to be sought for. A prolapsed 
ovary or tube may tw felt on one side of the cervix and an excursion 
to one of the sacro-iliac joints may, in rare easels, detect tenderness 
aad induration there. 

Palpating the normal ovary by the bimanual touch is a difficult 
ttc*r unless all the conditions are favorable. These niv, a |>atient 
h thin and relaxed alxlominal walls and an injurf^l perineum, 
rruler such circumstances the ovary may be rolled between the 
fingers of the examiner's hands. Whenever the ovary is enlarged 
from any cause it^ palpation is rendered easier In the case of 
rigid abdominal walls, large dejjosits of fat in these structures, a 
tight hymen and unyielding perineum, tlie palpation of the ovary 
beromes difficult. Often only the uniler surface can be felt, and 
'Wnetimes only by a rectal examination. Note the sensitiveness 
to pressure of the normal ovary and in the case of a diseased ovary 
inquire of the patient if the pain caused by pressure is the same as 
that suffered at other times. 

The Fallopian tube can not be felt by bimanual examination 

less it is thickened or enlarged by disease. In this event it 



42 PHYSICAL EXAMINATION 

may be mappal out with varying degrees of exactness according 
to the condition of abdominal wall and perineum. 

An abscess in the pelvis, whether originating in the tube, the 
ovary, the vermiform appendix, the sacro-iliac joint, or coming 
from above in the psoas muscle, may be mapped out by the bi- 
manual touch and a point of fluctuation found if it exists. 




I 



HI. The examination {rontmtu*d) —- ^, Palpation (row/ miW) : Anatomy 
at the pelvic contents, p. 4*1 Barriers to infection, p. All. Mobility of the 
litem** p. 44. The uterine ligaments* p. 44. Meclianics of the f>eivic and 
ftbdouiinaJ contents* p. 44. The f>elvic circulation, p. 4(1. The normal 
position of the uterus, p. 49. Stroctyres to be distio|Tt(ished by palpation, 
p. 49, Inferences to be drawn from palpation, p. *jO. (c) The rectal touch, 
p, 50. {d) The recto-ab<Jominal touch, p* 5>i. (c) Gynecological [wisitions 
otlier than the dorsal position, p, .5.S: The Sims fMJsilion, p. 54: The knee- 
ehest pi>sition« p. ,56; The lithotomy position, p. 57: The raised j^wlvis 
fiosition, p. 58; The standing position^ p, 59. 

4. Odor as a dijignoslic sign, p, tK). 

5. The ci>llection of the dischnrges an«l tissues for microscopic examina- 
tion, p. tJI : Bartholin'?^ glands, p. iU. Skene*s glands, p. <>L The 
rervieal canal, p. 04, The preservation of tissue* p. Olt. 



III. THE EXAMINATION {Continued) 
3. Palpation {Coniintied) 

Befork describing fyrth*T the pathological conditions which 
may be diagnosc'd by the Ijiiuaniial touch, it w ill Ik- well to n^vievv 
Borne points in the anatomy, phyi^iology, and nieehanies of the pelvic 
No attempt will Ix* made to give a complete dcscriptioti 
BB may be found in text-tooks of anatomy. 

Think of the pelvic as a box^ elowil l^elow by a flexible diaphragm, 
the jielvic floor, and open aljove into the alxlominal cavity* Dirtrt 
eamniunication l)etw(M-n the pelvic cavity and th** outside worlil 
»f«teblish<?<l through the lumen of the Fallui>ian tubes, the uterine 
ca\ity. and the vagina. The harriprs to the entrance of infective 
bfirteria to the peritoneum are (1) the narrowings of the canals 
at the isthmus of the tidx*, the internal os of the uterus, and the 
hymen, and (2) the downward current of the s<'cretions, partially 
maintained by the cilia of the lining epithelial ct4ls, partly by 
pemU^hm of the tube, and also by coughing and straining. 

45 



41 



Pins ICAL EXAM IN AT ION 



Tho uterus oeeupyiiig the ceiittT of the pr^vif eavity is susix^iKledl 
with ite; hm^ axis coinciding with the long axis of the pelvis anrl at I 
right anglcB to the long axii? of the vagina. An important point 
to remember is that it h suspended and oscillates every time its 
owner couglis, sneezes, laughs, or moves alwut. It is held ui jilacc 
by certain ligaments to which it is attached, by its connection with 
the vagiiia, by the jjelvic floor supporting the vagina, and by the 
pressure of the alKlominal contents. 

The ligam(*nts are folds of peritoneum containing eonnt^ctive 
tissue, vessels, and ncrvTs, and, in tlie ease of the roimd and utero-d 



Fig. 6.— Vertical Median Section of Body. (Kelly,) 

saeral ligaments, a fi^vv muscle fibers. The broad ligaments are 
on both sfde^ with long attachments to the sides of the uterus, 
thick at their lower jwrtions, reaching from the cervix nearly to the 
ftmdus and attached at their other ends to the sides of the pelvis. 
At the back are the utero-saeral ligaments, attached to the pt^sterior 
surface of the uterus at the region of the internal os and extending 
to the back wall of the pelvis at the level of the second or third 
piece of the sacrum. The utero- vesical eonnective tissue is in front 
and also the round ligaments, which begin as large fleshy cords 




I 



I 



just in front of eac-h honi of the uteru.s and extend to thr internal 
abdominal rings, becoming smaller and .sniaJler a^ they apj>roach 
their insertion in the fat of tlie pul>e8. 

It is to Ik? noted that \vli(*n a winnan is in the ereet position (see 
Fig. 6) the in^sertions and origins of th<* round hganir^nts He 
practically in the same horizontal plane, thert^fore these ligaments 
act rather as steadying guys than a.s snpports to tlie uterus. In 
the case of the broad tiganu*nts they are thick and strong in their 
lower jxirtions and really siip[)ort. the eer\ix. So also the iitfTO- 
sacral ligaments supjiort- the lower uterine segment and tlii'ough 
it the upjjer vagina. The attachments of the vagina to the cervix 
Hcrve to steatly this jK^rtion of tlic organ and keep it in its profxT 
relation to the pelvic floor. The supporting 

tion of the pelvic floor will be found de- 

ibctl in more diiail in the section on pro- 
h\m^, Chapter XI\ , im^** --'^' 

The abtlominal cavity may be likened to 
upright cylindrical vessel filled with wat^r 

od clogied at !)oth ends by an (*lastic mem- 
b^m<^ Tlie weight of the water causes thr 
bottom membrane to bulge outwanl and the 
pre^ssun- of the atmosphei*e the top menibrHne 
toank inward. 

In the cai*e of a liv^uig woman, stantling 
iTiK't, the diajjliragm rf^presents the top mem- 
brane, theix-lvic HfKir tlie lx»ttom memhnui«% 
the walL^ of the alxlomen the vessel, ami the 




Tig. 7. —A Vt?rtit'al 
(VhiidtT closed at either 

liver^ stomach, spl**en, kidneys, pancrea^s, in- Kud by an Elaati> Dia- 
ic0liii€9, and utrrine organs the fluid. The P^*'*:*^"^ ^^^i Filled with 
posterior wall of the alj<lonien is practicafly 
immovable like the walls of the tube, but the anterior wall ia elastic 
B<1 capable of v^arjnng within wiile limits, not only the capacity of 
beatxiominal cavity, but the pressure exerted on its contents. 
The contents of the aUlorninal cavity are solid, fluid, and gaseous, 
aad the different structures are stowal 1*0 closely together that 
then? i.*^ no waste ??[)ace between them. The jiressure which can 
be e-xertinl on a solid organ in the aJKlominal ca\ity such as the 
livi?r, ha^ 110 eff<H't other than to compress it slightly or cause- it to 
move within the limits permitted by its susfxmding ligaments. 



46 PHYSICAL EXAMINATION 

According to a law of jiliysics, pressure on the fluid contents of a 
closed vessel is transmitted with ecjual intensity in all directions. 
Pressure on the gaseous contents has no other eflfect than slightly to 
lessen their volume. The abdominal organs are supported by their 
ligaments and mesenteries, by each other, by the abdominal walls, 
— the upper ones by the ribs, — by the anterior projecting lumbar 
spine, and by tlu* shelf of the false pelvis covered by the psoas 
nmscles. (See Fig. 86, page 221.) Therefore, when the woman is 
in th(j erect posture the weight of the abdominal contents, minus 
what is assumed l)y the mesent(Ties and the abdominal walls, rests 
on the anterior face of the lumbar spine and the slanting brim of 
the false pelvis, on the lower anterior abdominal wall, and also on 
the posterior surface of the uterus and the broad ligaments and 
through them on the i)elvic floor. Increased pressure due to eon- 
traction of the abdominal walls, strainhig; or downward excursion 
of the diaphragm, coughing and sneezing; is transmitted to the 
fluid contents in all directions. The posterior walls of the abdomen 
are rigid, the anterior walls are rigid when contracted, the bony 
wall of the pelvis is rigid, the pelvic floor is elastic, therefore it 
bulges downward, like the membrane on the bottom of the vessel 
in the figure. 

If histead of Ixing in the erect posture the woman is in the 
knecvchest position, the conditions are reversed. Now the weight 
of the abdominal contents comes on the diaphragm and the upper 
front walls of the alxlomen, the p(Jvic floor is depressed inward 
like the upper meml)rane covering the vessel ; when the vagina, rec- 
tum, or bla(ld(T is open(Hl, air rushes in to replace the negative 
pressure, thus maintahiing the ecjuilibrium of the atmosphere, 
fifteen pounds' pn^ssure to the scjuare inch exerted in all directions. 

In this connection the pelvic circulation is to be considered. 
Enmiet pointed out long ago (Trans, Amer, Gijn. Soc.j 1887, Vol. 
XII., p. 65) that the veins of the pelvis are without valves, and 
to overcome the eff(»ct of gravity their course is extremely tortuous. 
** Moreover, this provision is necessary that undue traction be 
not made upon the vessels with the change of position, and with 
th(^ incn^asing Inilk of th(» uterus d(»pending upon gestation." He 
not(»d th(* fact that if we draw down a healthy uterus to a certain 
point near th(» floor of tlu^ p(»lvis and hold it thcTC, the cervix and 
vaginal mucosa become congested very soon, as evidenced by the 



48 



PHYSICAL EXAMINATION 



dark color of the tissues, denoting vcnOits congestion due to straight- 
ening out of the tortuous arteries and vein^. f 

If the traetion is continued until a portion of the uterus projects 
from the vagina, the tissues become l>Ianehed. This is thought 
to be due to a stretching out and a lessening of the caliber of the 
arteries so that the blood supply is cut off. The connective tissueBl 



Fig. 9,— The Contents of the PelvU from Above. (Kelly,) j 

of the pelvis is as the trellis to the grajx^viiie, the pelvic fascia 
serving as a firm support for tht^ whok\ 

On each side* of the uterus arc the ovaries floating, as it were, 
on the posterior surface of the broa<:i ligaments, and the Fallopian 
tubes extfiiding from both sides of the fuutlus uteri to the outer 
extremities of the ovaries. The ovaries and the fimbriated ends 
of the tubea are steadied at their outer ends by the infimdibulo 
pelvic ligaments, otherwise their movements are regulated by the 



PALPATION 



49 



I 



the 

I titu 

m 



movements of the uterus, broaci ligaments, and the abdomiBftl 
contents. 

The blaiMer, when RIIimI, |>ushes th(* uterus and the ovaries and 
the tulx*45 backward, ten<iing to cause retroversion. The rectum, 
occupying the left posterior portion of the pelvis, when distended 
tendji to raise the uterus and also makes for retroversion, because 
limiting the Imckwaixl excursion of the cervix. 

It is plain, thn^, that the normal position of the uterus varies 
s^oniewhut acconling as the woman is stajiding or is lying down, 
it being nimewhat more antevertcil in the former and less ante- 
vertetl in the latter, Ix^mnse of the effect of gravity and the vary- 
ing pressure of the aUlominal contents on the fundus. Also its 
|}06ition a^ well as its mobility varices according to the state of 
fuUiieJ^*' of the bladiler and the rectum. 

In praclicuig bimanual palpation the following structures are to 
be felt: thesymphvMb pubis; the promontory of the sacrum; the 
utenji<: the ovaries; the Fallopian tulx^s, when disi^ascd so that they 
are thickent^l or enlargcnl; the appendix vermiformis, verj^ excep- 
tionally and only when thickened or enlargetl by dis<^mis<% tlie rwtum 
bladder, onIy» a.^ a rule, when their walls arc thickened, 
rare cases having lax and thin abtominal parietes a thick- 
1 un.'ter may Ix^ pa]i)ate<l at tlie point where it crosiites the 
ie brim just outside the internal iliac artery ant I the sacro 
Bia€ joint. A thirkenr*d ureter may be felt always for two inches 
or 9f> after it leaves the bladder. In favoraljle ciLses the normal 
ureters may bc^ palpated per vaginam, but this is a fine point and 
not an a4*complishm(*nt of many physicians. 

On ttiaking downward jtressure on tlir alxlomen the |iromontory 
of the «acrum is felt just below the level of the umbilicus. Midway 
between the promontorj^ and the symphysis pubis, or a trifle nearer 
the symphyRiB, the fundus uteri, if normally placed, is to he made 
out. In the erect posture the external os uteri is on a level with 
the upper margin of tht* sym|*hysis pubis; in the recumbent at- 
titude the o» in slightly higher. 

tesrlying the cer%ix with the vaginal finger the examiner moves 

uti-ru-s up and down and from side to side, thus gaining an 

idsA of the mobility, whether normal or limite<l by past or present 

ioflammBtory action in the surrounding tissues, or by a tumor or 

t full bladder. 




50 



PHYHICAL EXAMINATION 



The uterus may be displacetl as a whole downward in the axis 
of the pelvis (prolapse)^ or backward (retroposition), or exc(*p- 
tionally upward. AJterations in the axis constitute retroversion 
(oft(*n made to include retroposition) and anteversion. Lateral 
versions are of little imiwrtanee. 

Besides the situation, axis, and mobility of the uterus, one notes 
its form (abnormalities^ flexions, and tumors)^ its size (atropiiic 
or liypertrophic), and its density (soft in prt^gnancy and septic 
conditions and hard in chronic inflammation and in many tumors). 



Fig. %a. — ^Norraal Female PeKis- 

Phjssure on the uterine bo<ly ehcitini^ tenderness denotes en* 
dometritis; and tenderness of the cervix, endocendcitis. 

Tumors anjTvhere in tlie {x^lvis arc to (k* placed accurately, antl 
their size, form, consistency, and seiLsitiveness to jjifasure de- 
termined, also their relation to the }x4vic organs. This relation 
is established often by moving the tumor and noting if the uterus 
moves, or \ice veiisa. 

In acute ix^lvic inflammation the alxlominal walls are apt to be 
rigid because of the peritonismus which is g(^nerally present Under 
tliest* conditions little can be learned e\eej>t by the vaginal touch. 

Exceptionally it is best to combine instruments with the bi- 
manual touch as descrilM'd in Chapter \TL 

(r) The Rectal Touch. — This method of examination is resoHnl 
to io order to gain a slightly higlicr reach in the jx*lvis aiid also in 



11 



PA Lr AT ION 



51 



where it Is inativisal)lr Ut nmkv the vaginal tuucli, as in 
young pris, a virgin with a rigid h>Tnen, the case of a narrow, 
Aallow vagina, or a eongeriital or aetjuired atresia of this organ. 

In making a reetal examination it is desirable to use a large 
Hinount of kibrieant beeaiise of the tightness of the anus. Tlie 
digital examination of the rectum causers much more discomfort 
to most women than the digital examination of the vagina. There- 
fore, every reasonable de\'iee should Ix^ emijlnyed to k\sseu the 
diHcomfort, and also, unless the finger is well lubricated, the anus 
wUl grasp it so tightly as to interfere \\ith its tactile sc^nse. It is 
jrell to use a thin rubbcT r<^t for the reetum, removing it as soon as 
ihiit part of the examination is over. Bt'f(»re making the examina- 
tion the anal region is smeared frf^'ly with mnco-lubricans and the 
left forejfingcr is thoroughly anointed a,s welK 

Sometimes in pati(*nts who are annoyiHl by an accumulation 
of gas in the rectum it is well to Ir^t this gas out U^fore making the 
examination, by passiJig a eatht^ter through the anus Ix'fore in- 
triKlucing the finger. As a rule, however, the presi^nce of gas in 
the rectum facilitates the examination. The vaginal touchy if 
it has preceded the recta! touch, will give an inkling as to the 
cfjndition of the rectum. Thi* prestiice of ft-cal matter calls for 

«mema, 

'In pa.si?ing the fingcT through tlie aims, nolf tin* tonicity and 

stmngth of the sphincter ani. In the cast* of hemorrhoids or 

fissurt^. where there haslx^en long-standing irritation with consiMjuent 

increased miLscular action, tht* sphincter will be found in many 

ranes to be h>'pertroplu<:d. The s{)hincter may be weak and 

ft inmifficient becaase of injury re<^eived dming childbirth or by over- 

^L^trt*tehtng at the hands of a surgeon, or in cases of rectal prolapse 

preatrophic catarrh. 

■ A fiasun? by prest*nting a lrK*alized point of sc^nsitiveness, hem- 
^^^rrhoids by giving a fettling of lumps in the rectal wall, and also 
^^|Kil>*pi by their firling of ixilunculatton, may Ix' detectetl Ijy 
P tooeh. The situation of tlie ojM^ning of a fistula in ano into the 
bowel CAO not be determined without the aid of a |>roh<». Through 
tin* thin anterior rectal wall the <'xamining fingt^r makes out the 
c«^TX^ the basc*s of th*^ broad ligaments, and thi' ntrro-sncral liga- 
Ru*fiiB. By raising the utenis, these ligaments are put *>n the 
stretch and an i<lea may be obtained as to their relative length 




52 



PHYSICAL EXAMINATION 



and thickness. The posterior wall of the nti^rus is vfry accessible 
through the rectum. 

The ovaries and tubes if prolapsed may Ih^ i)aiimted advanta- 
geously by the rectal touch, 

Thruugli tlie posterior wall of the rectum the coccygeal and 
sacral vertebra^ may be felt, and fractures and dislocations of the 
coccyx determined. Pain caused by pressure on the coccyx may 
mean coecygodynia, (See Chapter X,, page l.>9.) 

Infiltrations or new growtlis iii tlie recto-vaginal septum are 
to f>e mapixxl out, as to size, situation, consistency, and sensitive- 



V 



.^ 



Fi«. lU. — Haifa Fi'jujilu Ft l\ j , >iMA\iui: Am>.iljiliiy uf louttnLstii i*:ilpiaiim. 

ness, by combined vaginal and rectal touch, the finger of one hand 
being ui the vagina, and the forefinger of the other hand in the 
rectunu The (jresence of new growths and strictures in the 
rectum is diagiioscfl by the rectal touch. 

Too great care (*an not be exercised in washing the hands before 
changing from a rectal to a vaginal examination anrl vice versa, 
IrMH^ause of the danger of transferring inft^cth't^ matter from one organ 
to the other. In the case of acytu inhMnive inflanunation of the 
vulva and vagina, it is wiser not to examine tht* rectum at all. 
Often the rt^ctal examination may be tleferred as well to a later date. 




In. n — Tlif Siniv IV>8iiinri. 

for oxplomtiofi of the ('idHlixsa*' n{ Dny^las and its contents, than 
by ihr bimajiual va^ino-abdoiniiial toiicli. 

I%ital exploration of the blaildiTisan iinjustifiahlr proccilure, as 
all the infomiation ol^tainetl liy touch may 1k^ ^ainnl i>y a si>CTuluni 
fxatuiiiation ami by vaginal and n^ftal tonrh. The' danger of 
ineontinrace of urine is too gn^at. to justify introducing the finger 
through tin* ur«*fhra, no matter ln»\v i^niall the finder may h\ 

(e) Gynecological Positions other than the Dorsal Position. — 
Bi!!%ick*s the tlorsal position wliich has Ixn-n ileserilx^d ah"<^tuiy, there 
an» ae^Tral other fxis^itions ijito which the patient is put for pitf- 
poees of examination. 




54 



PHYSICAL EXAMINATION 



They are: — the Sims, the knee-chest, the Hthotomy, the raised 
pelvis, and the standing positions. 

The Sims position is not so frequently used now as in the years 
following the invention of the Sims speculum. Still, it is of great 
service both for the use of the speculum and other instruments, 
for practicing the bimanual touch, and for examination of the anus 
and rectum. For some reason not altogether clear, the illustra- 
tions hitroduced into all but one or two text-books on gynecology 
to show this i)osition, do not figure it correctly as it was devised 

by Sims or as it is used in 
the hospital where he did 
his work, the Woman's 
Hospital in the State of 
New York. As commonly 
shown, the patient is lying 
on her left side with thighs 
only partly flexed on the 
abdomen, hi the middle of 
a long table; her head is 
generally on the left side 
of the table, her hips in the 
middle, and so far from the 
bottom edge that the gen- 
itals are entirely inaccess- 
ible for examination. 

Suppose we have finished 
with the dorsal position 
and wish to put our pati(»nt 
in the Sims position. Pull- 
ing the sheet off and holding it in front of her we give her a hand 
and ask her to stand in the chair at the foot of the table. Then 
we pull out the little slide for a foot rest in the right-hand lower 
comer of the table and place the pillow for the head diagonally 
about midway along the right edge of the table. Now we ask her 
to raise her skirts and to sit on the left-hand comer of the table, 
sitting as far over to the left as she can and tuming on her left 
side and drawing up her knees as she lies down. Throw the sheet 
over the hips as soon as she gets down. N(»xt ask her to put her 
left arm ov(t the left edg(» of the table and h(»lp her to do it. 




Fig. 12. — Diagram of the Sims Position. 



PALPATION 



55 



See that her ht^ti ij^ on ilir pillow on the light side and that she 
is, as it were, tloubled up like a jack-knife. Then the physician 
stands on the left of the table facing the patient's hips, pulls them 
(asking at the same time for the patient's assistance) to the left, 
until the back of the sacrum h even with the left edge of the table, 
and the lower margin of the buttocks corresjionds witli the lower 
etige of the table. The fi^et are now on tlic foot rest, oi', in 
ciefault of this, on the hack of a chair padded with a foldefl blanket, 
ar on a table. The upjK-r, the right kntn^ is advance<l a httle 
beyond its fellow, anfl the inner edge of the sole of the right foot 
rt^ts on the instep of the U'ft foot. 

A fresh towel opened out is made to cover the lower buttoek 
and thigh by tucking one en<i info the drawers behind, and carry- 
ing thi* other end lietween the thighs in frcmt, Th*^ (wc end Ix'low 
is tiickwl under the covering of the table. The upjx'r l>yttoc*k 
and ttiigh, the legs and feet» and the rest of the Ixxly are covered 
by the shef*t. 

In this jxjsition the jK'Ivis is inclined at a slight angle to tht^ 
table^ the ablominal contents fall away from the pelvis, leaving 
the j>el\ic organs frt^e from pressure; the alxloiuinul walls are 
rr-laxotl and the vagina, Imllooned by air admitted by the speculum, 
can bo most easily inspected. 

It is difficult to put very stout women, or patients with large 
abdominal tumors, in this position an*! in thesc^ cases the Sims 
position is of less value than in thiimer subjiHi'ts, 

The injfx>rtant pobits are to get tlie patient's back on a level 

th the left <*<lge of the tal>!e and the heatl on the right edge of 
:he table. Unless the patient is fait in the correct position it is of 
no value what<»ver, Trik'ss the tliighs an* shaiply flexed on the 
abrlomen antl the hips are at the edge of the table, the pliysieian 
can neither look into the vagina nor make manipulations to ad- 
\*antage. 

The bimanual vaginoabdominal or reeto-abdomina! touch is 
made with the patient in the Sinis (xjsition by introducing the left 
f '' r in either vagina or rectum and the right hand between 
t r i_ tis^ a^jking the patient to raise her right tliigh until the hantl 
is in place and then letting it dro)> again. 

Ilie Sini.s position is useful also for palpating uterine antl ova- 
rian tumors; \iith the patient in this position, relaxation of the 



56 PHYSICAL EXAMINATION 

abdominal walls may Ix^ obtaincil often . when it can not be with 
the patient m the doi-sal position. 

The knee-chest pomiion, or knce-elbjw position, as it is some- 
times called, is anotlier gynecological position commonly ^wougly 
figured in the text- books. The patient stands in the chair at the 
foot of the examining table facmg the table. She raises her skirts 
in front an<l (ilaces one knee near one comer of the table, the other 



4 




il 



Fm. 13.— The Ivnee-Chest Position. 

knee follows and takes its place at the opposite comer of the 
table. Then she lx*nds fonv^ard and places her hands in the middle 
of the table while the physician throws the sheet o\^er her. The 
feet and legs are left projecting over the table's edge, but the 
position is not uncomfortable, for all the weight comes on the 
knees and hands. Now the patient is on her hands and knees on 
the table. The physician folds a gooil-sized pillow once and 




PALPATION 



57 



place's? it in the tiiidiilc of tlu* tabic. The imtient is askecl to place 
her head and chest on the pillow with her face to one side, letting 
het>!e]f down on to her elbows as she does so. The physician next 
goes to the foot of the table, throws the skiits abive the hipH 
under the sheet and drapes each thigh with the sides of the sheet. 
Note now whether the thighs aj*e vertical. They are apt not to 

■ be, as tlie fjatient generally throws her chest too far forward, thus 
^^^elaiiting the thighs. If they are not vt^rtical tliey an* t'asiiy niade 
^^■d by asking the patient to move her chest back a little as the 

■ pillow is niove<.l for her in the same direction. 

I The knee^'hest position is rnost useful ff>r spcHniluo! examina- 




ul' \ ti \v\ Shnwiu^ WrtjcaJ Thighs. 



tiofii? of the vagina, bladder, and rectum, tfie MlMlominal pressure 
bf'ing n'moved, and the viscus in whicli the sp4*(*ulym is plannl 
fieing Jmllooned hy the atmospheric pressure admitted by opening 
the t*xtc*mal oriBcc. 

To replace a retrovt^rteii or retroflexe<l incarcerated uterus, 
or an incarcerated tumor of the pehns, often necea^ary to est a Wish 
a dia,i^nsi.**, the knee-chest [msition is invaluable. 
Tfw lithotomy ptmtwn is the dorsal ix)sition with the thighs 
ced on the abdomen. The jKisition is maintained by leg holders, 
nf the Von Ott, Robb, or the Clover's crutch patterns, bj^ different 
foftDs of slings holding the flexed thighs to the shoulders of the 



J 



58 



PHYSK A L liXAM 1 NAT 1( >N 



patiriit wUh .straps, or hy Ir^ iKiIdrrs jitt ached to tlir o|jmitiiigj 
table. The ijatient is placeii hi the lithotoiiry positioii just aa| 
hi the (lorsiil jjosition, with the addition tliat the thi*rhs are kept 
Hexed by some deviee. Without any a[>[)aratys whatever it is 
posvsiblo, and often convenient, esp^x-ially in short operattonSyfl 
such as curetting, for one assistant to hold bioth legs with one 
hand and Imve tlie otlier hand free to assist tlie physician. To 
do this, the assistant, generally a nurse^ places herself on the left 
side of the table (the patient's right side), facing the physician, who < 



is seated in the chair at the foot of the table. She reaches across the 
patient's flexed limbs with her left arm, letting the right knee rest 
m her left axilla and grasping the left If^g with her left hand. Thus 
her right hand is free to hold instruments for the doctor. 

The lithotomy position is used for examtnatiojis under etlicr, 
for operations, and for investigations wh*»re it is ntressary to 
scrub up atid asc])ticize tlie vulva and surrounding regions. 

The raised pelvis jx)sitimi, us<h1 only in eystoscopic exaruina- 
tions, is an exaggerated lithotomy position. It is best obtainetl 
on a table which lias a mecliaidsni for the Trendelenburg posture. 




PALPATION 



59 



I 



but may tie wctutimI by placing a liUix^H^k uv hiinl ctishinns rdvrnMl 
with towi'Ls under llu^ satTuni, so that tlu* [H'ivis is plcvatt'd alxjut 
trn inchoii above the level of the table, the k^gs lieing hM Ijy a 
Uobb leg holder or by an assistant standing on a stool or I>ox, 
This pa-^ition tilt?; the pelvis backward and removes abdominal 
I>R*ssure from the bladder. 

The standing position is of occasional use in determining the 
ilcgree of prolapse of the uterus and Viiginal walls when full al>- 
doruinaJ pressure is exerted, also the axis of the uterus under these 
(nnditions, and the holding power of a pessary. 



Fio. Hi,— Tilt- liiiised Pelvis Position. 

The patient stands facing the physician with her right foot 
rufting on a round of a chair eiglit or ten inches from the Hoon 
The physician kiicels on his left knee in front of her, or sits in a 
low chair restuig his left ellniw on his left knee. He anoints his 
left forefinger, and j?temlying himjs4*lf with his right hanti on her 
Mt hip, finds the vulva by sw^ee|>ing the anointed middle finger 
of hi.H left hand over the anal n^gion, and then introduces the fort*- 
finder, ju8t a^ in the vaginal examination in the case of the dorsal 
fjOHition* Having the patient bear down or cough gives an itiea 
to the excursion of the uterus with forcetl expiration. 




COLLECTION OF DLSCHARGES AND TISSUES 



61 



Acetonemiai a fonn of intoxication with acetone occurring in 
diabetes, in infectious fevers, in intestinal fcmicntation, in gen- 
t^ral sepsis, and sometimes following g>mecologieal o]>erations, 
may be distinguished by the sweetish odor of the l^rcath^ 
described as like that of a pippin apple. 

5, The Collection of the Disch arches .\nd Tissues for 
Microscopic Examination 

Ifiaterials Needed.— L Half a dozen fitisolutely clean cover 
gla^^'H. 2. A few euJture tubes of hydrocele agar or blo<>d yeriini 
(furnished by the pathologist), 3. Platinum wire loo|). 4. Alcohol 
lamp. 5. I^ng-handled i^harp knife. 6. Loug-hantlled f^hari> 
pointt*<J scissors. 7. Uterine tetiaculutu. 8. Uterine dressing for- 
ceps. 9. Needle-holder, curveci neetUe, and catgut. 10. Gauze 
packing. 11. Small bottle of ten-per-cent formalin. 

Bartholin's Glands. — If the dis(*harge from the glands of Bar- 
tholin is to b* collected for examination for gonocoeci or tubercle 
t»acilli, the labia are sc^jjarattnl and the vulva is wiped dry with 
sterile cotton i>leilgets. Grasp the gland to l>e investigated be- 
twfX'n the thumb and forefinger, makt* gentle pressure. an<l transfer 
the dischai-ge^ which exudes from tlie innutli of the gland's tlut-t. to 
a cover glaa^ by means of a platinum wire loop or uterine applicator 
which ha.s Inx^n passed piTviously througli the flame of an alcohol 
lamp. Place a clean cover glass upon the* first oiu^ press the two 
gently tfjgi'ther to spread the discharge evenly, sliile the two a|>art, 
and allow to dry. The dry cover gla.sse8 may then Ik* reajjplied 
face to face and held together by an elastic tmnd. They are then 
placet! m an envelope which is labeled as follows: — 

Name of patient: 

Date: 

Source of material: 

Examine for (organism): 

Sent by Dr. 

The preparation properly labeled is then sent to the pathol- 
ogist for examination. 

Skene's Glands.— The orifice of the uj*ethra and the introitus 
vaginir are wiped dry with sierile i-otton pledgets. Introduce the 
finger bto the vagina and make gentle pressure from above do^Ti- 




62 PHYSICAL EXAMINATION 

ward along the course of the urethra. As the ducts of Skene's 
glands open mto the urethra just inside the urethral labia, any 
discharge from these ducts will contain a certain admixture of 
urethral discharge also. The urethra can hardly become infected 
without accompanying infection of Skene's glands, but this mixture 
with urethral discharge is unimportant from a clinical standpoint. 
If it is essential to examme the discharge from Skene's glands apart 
from that from the urethra, then the latter canal must be walled 
off with a small cotton pledget and pressure made only over Skene's 
gland. Transfer the discharge obtained to cover glasses as de- 
scribed under Bartholin's glands. 

The Cervical Canal. — The patient is placed in the Sims position 
by preference, although the procedure may be successfully carried 
out in the dorsal position. A speculum is introduced and the 
vagina cleansed with sterile cotton and water and then dried with 
dry cotton. A good exposure of the cervix can usually be obtained 
without the use of a tenaculum. The use of a tenaculum is often 
accompanied by bleeding which may contammate the cervical 
discharge. Sometimes it is necessary to draw the cervix down 
with a tenaculum. In this case the instrument should be firmly 
fixed at the first attempt and held in place. A sterile tampon 
screw is most useful in obtaining cervical discharge. The instru- 
ment is introduced into the cervical canal not beyond the internal 
OS and twisted mitil some of the discharge has been caught in the 
threads of the screw. WTiether obtained with the screw or with 
the platinum wire loop the smear is made as described in the case 
of the glands of Bartholin and Skene. 

Cultures. — If cultures for the purpose of obtaining a bacterial 
growth from a discharge are to be made, the culture tubes are 
used. Collect a drop of the discharge on the sterile small wire 
loop which comes with the tube and smear it over the slanting 
surface of the material in the tube. Replace stopper, label care- 
fully, and return to the pathologist. It is possible to introduce 
the small wire loop into most cervical canals without dilatation, and 
it is much better to take the culture or smear without dilating 
the canal, lx)cause in the process of dilating the discharges are 
partly removed and mixed with blood and tissue. 

Removal of Tissue from the Cervix for Examination.—- The Sims 
position usually offers the best exposure of the cervix for the 



COLLECTION OF DISCHARGES AND TISSUES 63 

removal of pieces of tissue for examination. In removing a 
suspicious piece of tissue for microscopic examination it is wise 
to cut out some of the apparently healthy tissue as well as the 
disi'asecl portion, for it occasionally happens that the pathologist 
receives nothing but necrotic tissue and can form from it no diag- 
nosis whatever. A raw surface left by removal of tissue should be 
closed by suture or tamponed until all bleeding has been checked. 
Tissues removed by the curette, scissors, or knife for the purpose 
of diagnosis, are to be plunged intact and immediately into a ten- 
per-cent solution of formalin in water; then they are properly 
labeled, and sent to the pathologist. 



CHAPTER VI 
THE PHYSICAL EXAMINATION (Continued) 

III. The examination (continued) : 6. Inspection of the abdomen, p. 64. 
Method of performing it, p. 65. Appearances to be noted, p. 65. En- 
teroptosis, p. 67. 

7. Palpation of the abdomen, p. 68. Method of performing it, p. 69. 
Points to be determined by palpation, p. 69. Palpation of the kidneys, p. 
70. 

8. Percussion of the abdomen, p. 71 ; Auscultation of the abdomen, p. 
72 ; Mensuration of the abdomen, p. 74 ; Gauze records of abdominal 
tumors, p. 74; The X-rays in diagnosis, p. 76. 

III. THE EXAMINATION (Continued) 

6. Inspection of the Abdomen 

Attention will be directed to the abdomen to a greater or a 
less degree according to the nature of the disease present in any 
given instance. In the case of late pregnancy, and of tumors of 
abdominal evolution, whether originating in the pelvis or not, 
investigation of the abdomen is of chi(»f importance. 

In suspected uterine disease the vaginal and bimanual examina- 
tions usually precede the examination of the alxlomen. In the 
case of a large abdominal swelling the abdomen is first inspected. 

For the examination of the abdomen it is not so necessary that 
the pati(mt should lie on a hard surface as in the case of the vaginal 
examination. However, the table is mos1; convenient for the 
physician because he can stand up and make his ins{Xiction, palpa- 
tion, percussion, and mensuration when in a position comfortable 
to himself; not, as in the case where the patient is on a low bed or 
couch, with bent back and strained muscles, conditions which are 
not conducive to most careful investigation. The patient on a 
table is comfortable enough for the brief time required for the 
examination. 

All the patient^s clothing has been loosened and the corsets 

64 



mSPETTtON OF THE ABDOMEN 



remove<I, an previously (li*stTibt*d, Tlie 8lu*et eovei's tla^ legs, 

■ thigb^y antl pubic rvgioii. Tlu* raisiMl skirts covlt the chest, or, 

if the skirt^s have Ix^cn renio veil, another siieet is useil for this pur- 

To ijivestigate the alxlooien to the best advantage the pat lent ^s 
head j^hould bv miR^d a httlc on a pillow and the thighs should bc^ 
slightly flexed. Too much fl(^xing of tlie thighs or raising the head 
and thorax high will decrease the portion of the alxlomen available 
for cxaDiinatioru 

For purposes of deseri|>tion the alKlomen may be *lividcd 



f 



J:' 



£n«ifomj 
rartilagp 



Mariiii of rihi - 



Owt oi ilium - 



Spine of piibe» 

Flo. 18. — Tht* AlMlonien Dividtil into Quadrants 
and the Bony Landmarks Indicated. 

•^itrarily into four regions, liv two lines, one a vertical fine pans- 

iig tliruugh the ensifonn cartilage, the umbilicus, and the syrnphysis 

ibis, ancl the other passing through the umbilicus at right angle?® 

to the vertical line. The four regions &o made may he calletl the 

right upiKT <)uadrant, the right lowfT quadrant, the left u}iper 

rqumtrant, and {hv left hnver r|iiadrant. 

On oJj^erving the ahlonienone notices syiiimetry or as}7nmetry, 
listention or retraction, increased or diminishvd motion of (he 
^minal w^alls on res|nratioii^ and the ap|»eamnce of the skin. 



66 PHYSICAL EXAMINATION 

To detect symmetry, stand at the foot of the examining table and 
look at the abdomen from below. Tumors of the ovary as well as 
tumors of the kidney are apt to cause asymmetrical enlargement 
of the abdomen; whereas, tumors of the uterus and ascites more 
commonly produce symmetrical enlargement. One notes bulging 
in the flanks and a flattening of the anterior aspect of the abdomen 
due to ascites, or to lax abdominal walls, with or without an abnor- 
mal amount of fat in the panniculus adiposus. 

A tumor rising from the pelvis, unless of great size, is usually 
outlined by the abdominal walls. In ovarian cysts the abdomen 
is irregularly ovoid in shape with its point of greatest protuberance 
below the umbilicus, and there is no bulghig in the flanks. In 
the case of multilocular cysts the loculi may be distinguished by 
sight in exceptional cases through a thin abdominal wall, so nodules 
of a malignant growth in an ovarian cyvSt can sometimes be dis- 
tinguished by the eye. Large multiple fibroids also show occasion- 
ally through the skin as lumps of irregular shape; an interstitial 
fibroid forms a protuberance of a smoother outline that is generally 
situated in the median line. 

Observe the movements of the abdominal walls. The normal 
movements on inspiration and expiration extend over the entire 
surface? from ensiform to ])ubes. In cases of large tumors springing 
from the pelvic ca\aty the movement is confined to the epigastric 
region if the distention is great, also if there are adhesions between 
the tumor and the parietes there may be motion only in this region. 
Sometimes, when there are no adhesions present, the abdominal 
wall can be seen to glide up and down over the surface of a tumor 
of moderate size. 

Waves of peristalsis in the intestines may be noted in a patient 
with thin flaccid walls and retracted abdomen, also pulsations of 
the abdominal aorta. In pregnancy the situation of greatest in- 
tensity of fetal movements may be observed. 

Separation of the recti, due to distention of the abdomen during 
previous pregnancies, often leaves a ventral hernia through which 
a tumor, the i)regnant uterus, or the abdominal contents may 
protrud(\ Palpation of the abdominal and pelvic organs is ren- 
dered most easy in these cases. 

Th(» appearance of the skin of the abdomen is of interest as 
showing discolorations from blisters and counterirritants, indica- 



INSPECTION (i¥ THE ABDOMEN 



67 




K 



lions of previous treatment, also the presence of edema or skin 
di^Msases. Krjlargement of the superficial veins huHcates preasurr* 
on the deeper vessels. Excessive i!i«tention of thf* af>d()!n<^jj 
renders the skin white and glossy in appearance, whema^s, when the 
walk aix:^ lax, the skin has a shriveled or puekered look. 

The linea^ aibicantes, red and purple when ntTent, and white 
and glistening w^hen old, are to l»e looked for especially over the 
flanks. They indicate previous stretching of the skin» but are not 
pathognomonic of pregnancy, as they occur in 
virgins who have grown rapidly and then lost 
subeutAneous fat. 

Pigmentation of the linea alba (linea nigra) and 

increa.se of pigment atout the umbilicus and lower 

bdomen occur in some women during a first preg- 

ey. This pigmentation persists, but is of no 
diagnostic importance in a subst^quent pregnancy. 

When the patient is sick in lx*<! with peritonitis, 
the characteristic way in which she holds herself, 
with knees drawn up to relieve all stram on the 
abdominal parietes, is to be noted. 

Enteroptosis. — In some cases it is advantageous 
to put the i»atient in the standing position for the 
pur]>ose of ins|x*cting the ab<!omen: especially is 
this deirfrable in suspected ptosis of the akionii- 
nal \iscera, a condition often associated ^^ith 
uterine disease. 

Here w^e must inspect not the abdomen alone, 
but the entire tmnk. The patient stands, first, facing the phy- 
sician, entirely nude except for a sheet held by a nurse draping 
the lower limbs and pubic region. Then she stands so that he 
sees her in profile. In typical enteroptosis one notes a long, nar- 
row thorax, with flat and sunken epigastric rei::iori. The waist is 
kmgf the afxiomen is prominent, the shouldr rs are roundetl, and 
wboi aeen in profile the lower back is nearly flat instead of pre- 
wmtmg, as nonnally. a forward cur\T, with shoulders and hips well 
haelc and spine bent foi'ward in the lumbar region. There is gen- 
crally an abe^nce of a^lijiose t ksue in these patients and the muscles 

apt to be deniler and flabby. 



Flo. 19.— The 
Body Pose io 
Entc»ropto«i«. 




1 



68 PHYSICAL EXAMINATION 



7. Palpation of the Abdomen 

To palpate the abdomen successfully, the patient should be pre- 
pared as for hispection, that is, in the dorsal position with the head 
slightly raised on a pillow, all clothing loosened, the feet supported, 
and the pubic region, thighs, and legs covered by a sheet. The 
physician, standing on the patient's right, places both hands, 
wanned, and with finger nails cut short, on the abdomen. No 
abrupt or rapid movements should be made, and, for the purpose of 
distracting the patient's attention and thus favoring relaxation, 
it is ad\'isable at this juncture to ask some question as to the health, 
not directly referable to the abdomen. 

By care and patience the tendency of the abdominal muscles 
to contract when stimulated by manipulation may be overcome. 
Oftentimes more than one sitting is necessary to accomplish this 
result, and in this event the diagnosis must be held in abeyance 
until after a second examination. It is better to make two or more 
attempts, except in urgent cases, rather than resort to an examina- 
tion under an anesthetic, because with increasing experience the 
physician learns an added amount from each palpation, and hav- 
ing gained the patient's confidence and treating every case accord- 
ing to her individuality, he is able more frequently to dispense with 
an anesthetic. 

The utmost gentleness should obtain always. The harder the 
pressure, the greater the resistance of the abdominal walls and 
the greater the blunting of the physician's tactile sense. Further- 
more, it has happened several times in the experience of the writer, 
that a student novice has ruptured a thin-wallal or necrotic ovarian 
cyst or a circumscribed collection of peritonitic fluid, by too vig- 
orous palpation. 

A thin, relaxed abdominal wall permits of palpation of the 
promontory of the sacrum, and the pulsations of the abdominal 
aorta are to lx» felt distinctly. The anterior superior spines and 
the crests of the ilia, the symphysis pubis and the borders of the 
ribs, body landmarks, are always to \yc made out. Thick and 
tense alxlominal walls interfere with palpation. 

It is well to have a definite system to follow in palpating the 



PALPATION OF THE ABDOMEN 



69 



abduiueiL Begin with thr hnwv «iuatlraet8 and prcn'oetl to the 
Upper quadmnt.s, (See Figure 18, page 65.) By making firni 
but gt*ntle, dee|) |)res,sure, the (latient at the same time taking a 
tlt\'p lireath, the hands, flat on the alxlonien, are l*rought togi^her 
and a fold is graspeil l>etween them so that an estimate is formed 
of the thicknet^s of the alxlominai walls and their degret* of tension. 
Avoid as far as j)ossil)Ie iligging into the flesh with the tips of the 
fingers, UBing instead the palmar surfaces of the last phalaogcs, 
the location of the traineLl tactile sense. 

We may leam by paljmtion, of the presence of a tumor, also its 
situation, size^ shape, mobility, consistc^ncy, and point of attach- 
ment. We determine a |)ouit of tentleraess on pressure, indicating 
localized jxTitonitis. In a majority of cases we may palpate the 
nonnal kiibieys, more easily if they aiT enlarged or displaced. We 
palpate the eilge of the normal or enlarged liver, and a displaced 
liver, as in entcroptosis, also a distended gall bladder, or an en- 
larged spleen, A loop of bowel distended with feces and also the 
distended urinary bla<lder may \ye made out by palpation. 

Suppose* a tumor is presc^nt; first we di^crmine its situation 
by making gentle, firm pressure with both hautls, noting in wliieh 
cfuadrant or cfuadrants of the abdomen it is situate<l The ab- 
dominal walls should move with the hands over the untlerlying 
Of^ga&s or the tumon Tumors situatetl in the struct m-es of the 
alxlominai wall move with the wall on inspiration and expiration 
over the organs underneath. Tumors of the abdominal and pelvic 
organs that are adherent to the abdominal parietes limit the 
motion of the walls on respiration. Exceptionally, in cases wliere 
the walls are lax and the tumor is not excessively large, tht^ |>hy8ician 
m able to pick up the alxlominai wall and determine if it is adherent 
to the tumor beneath. All the alxlominai organs normally move 
more or less during respiration, — ^those organs nearer the iliaphragm, 
na the liver and kithieys, moving the most, while those in the 

' bottom of tlie abdomen are less affected. The size of the tumors 
can be learned only approximately. It is to be borne in mind that 

I MCBe tumors var>' m size at different times: for instance, an 
crvarian cyst is smaller after there has lH>en free catharsis from the 
bowels, and a fibroid tumor of the uterus is larger just befoi-e the 
eatanienia and smaller just after. 

The 8bape of the tumor is made out by palpating it in several 



70 PHYSICAL EXAMINATION 

directions. To this end the examiner shifts his position to the 
left side or to the foot of the examining table. 

The mobility of the tumor is ascertained by grasping it between 
the two hands and moving it about. Changing the patient's 
position to the lateral position may cause the tumor to fall by 
gravity to the dependent side. Ovarian tumors tend to gravitate 
into the abdominal ca\ity if the patient is put in the knee-chest 
position. The excursions of a movable tumor show us something 
as regards adhesions and the point of attachment and length of 
the pedicle. Traction on the jxxliclc generally causes pain re- 
ferred to the situation of the pedicle. 

The consistency of a tumor is often a difficult matter to pass on. 
Waves of fluctuation are made out by a combination of palpation 
and percussion. The hand of an assistant is placed, ulnar edge 
down, in the longitudinal axis of the alxlomen and firm pressure is 
made. This is to eliminate the wave which may be transmitted by 
the fat of the abdominal wall. The physician taps one side of the 
abdomen and notes with the other hand, placed on the opposite 
side, oscillations which may be transmitted through the fluid. 
If a cyst is filled so that the fluid is under great pressure and if 
the cyst walls arc thick, the fluid waves may be indistinguishable. 
So also, if the fluid is of a thick consistency, fluctuation may be 
absent. 

Peristaltic contractions of a piece of intestine are sometimes 
to be distinguished and also the rhythmical contractions of a 
pregnant uterus. To determine either of these it is necessary to 
let the hand rest gently on the abdomen for a considerable length of 
time. 

The point of attachment of a tumor may be learned by moving 
the tumor while the hand is held on a neighboring organ and noting 
whetluT the organ moves too, or by movmg the organ and noting 
the behavior of the tumor. 

Palpation of the Kidneys. — Palpation of the kidneys is best done 
with the patient in the dorsal position. The physician stands at 
the patient's side facing toward her head, his left hand is placed 
under the flank and his right hand over the flank, while the patient 
takes a dwp breath. This process is repeated, the hands coming 
together a little more with each expiration. Time, gentleness, and 
gradual movements are important factors in this manipulation. 



PERCUSSION OF THP: ABDOMEN 



n 



ITie rij^ht kidney, being a little lower than the left, is more accei^iblc 
to palpation. With pmctiee it will l>e found that tliero are com- 
paratively few cfLsn's^ — anil these patients having very stout and 
rigid-walled abtioniens, — in which the lower poles, at least, of the 

'kidneys can not Ix* felt. 

In the case of movable kichiey, generally the en tin* kiilney (*an 
be outlinefl, espeeially where it is enlargeih Pressure on a tuber- 
culous or hydronephrotic kiilney will frequently force turbid 
urine through the ureter into the bladder. If the bladder has 
lx*en emptitni by catheter previous to the examination and clear 
urine obtain<xI, suoli a tirwedure assists niaterinlly in establishing 
the diagnosis, for a second catheterizatio!i following paliiatioji 
draws off cloudy urine. 

To determine the extent of the downwanl excursion of a mis- 
winced kidney the flank is palpatetl eitlier in the sitting or in the 
iding jxxsition. In the sitting position the patient sits on the 
foot of the table with her feet in a chair, and lx»nds for%vard slight ly. 
In the standing position she stands fa<'ing the table and about a 
foot from it. Placing lx)th hands on the taiiie she leans forward 
so that imrt of her weight is taken on the handsj thus the ablom- 
inal muscles are relaxed. This nianif>ulation can Ix* executed 
bf«t with the asvsistance of a nurse or another woman, because the 

'patient can not hold up her locjsened clothing and tx-ar [>art of the 
weight on her hands at the same time. Personally, I have Itemed 
to place the chief reliance on the ilorsal position for |mlf>ation of 
the kidneys, except to make out the amount of extreme downward 
6XcurHion» when sometimes the standing, and at others the sitting, 
{xte^qtion gives the better result, 

8. Percussion, Auscultatio.v, and Mensuration of tuk 

Abdomen 



Tlie combination of pafpation and |)ercussion for the dettTtion 
kof fluid wav(*s in the abdouien has been described in the discussion 
of palpation. 

Peixussion is Ix'st practiced with the patient in the dorsal position. 
By it wr detemiine the situation of tlie hiwer margin of tlie liver- 
duUnes^f the area of stomach and colon tympany, splenic tiullness, 
tbf dullness due to fecal accumulations in the bowels or urine in 



72 PHYSICAL EXAMINATION 

tlie bladder, and the dullness caused by free fluid in the peritoneal 
cavity or by the fluid or solid constituents of a tumor. 

Unfortunately we have no standard of comparison in percussion. 
We can not compare the percussion note of one side of the abdomen 
with that of the other, and the conditions are constantly varying, 
due to changeable quantities of fluid, solid and gaseous matters 
in the stomach and bowels, and the encroachment of one organ on 
another. Also, there are to be considered the variations caused 
by the normal mobility of the abdominal organs. 

Neverthele^, percussion is a valuable adjunct to palpation. 
Its chief use in gynecological diagnosis is in differentiating between 
ascites and a cystic ovarian tumor. In the case of ascites, the flanks, 
being the dependent portion of the abdominal cavity and there- 
fore occupied by fluid, are dull to percussion. The intestines, 
filled more or less by gas, float on top of the fluid, and give an area 
of resonance in the umbilical region. Shifting the position of the 
patient to one side sends the fluid (unless by chance it is walled 
off by adhesions) to the dependent side, and the resonance is to be 
found on the upper side and flatness below. In rare cases, when 
the ascitic fluid greatly distends the abdomen, there may be no 
change in the area of dullness on shifting the position of the patient. 

In the ease of a large ovarian cyst, the resonance is in the epi- 
gastric region, the intestines having been forced there by the tumor 
and the dullness is over the an^a occupied by the tumor. Change 
of posture does not alter the areas of dullness and resonance. (S(k^ 
Figures 132 and 133.) If the gut has a short mesentery, the 
intestinal resonance may be in the upper parts of the flanks, or, 
in case the intestine is occupied by fluid or solid fecal matter, there 
may be little or no resonance, the entire abdomen being dull or 
flat to percussion. A large deposit of fat in the omentum may 
cause dullness in any situation. 

In gastroptosis one detects the displaced stomach by inflating it 
with gas by giving the patient a dram of bicarbonate of soda in 
half a glass of water, followed by half a dram of tartaric acid in 
another half-glass of water. Percussion is performed with the 
patient in the dorsal position and also in the standing position. 
The lower margin of the liver is percussed in these two positions 
and the differences of level noted. 

Ausctiltation is of value chiefly in diagnosing pregnancy. The 



AUSriTLTATfOiV f>F THK ABDOMEN 



73 



df*t4xrtiori of thv fctnl lirarWouuiLs, witli a ratr* riitirf y <li(Tomit 
from that of tJie iiiatrnial puls<% is one of tho al>8oliit(^ly (llstiiieiive 
signs of pregnancy. Th<*y ai'e seldom tlisternible Ix^fore the twen- 
tieth week, althoyiih eiTlain obMTvers report liaviri^ heard tht*ni 
a^ early a.^ th*^ twelfth w<*t'k. After tlie tweiity-t'ii^litli week they 
should almost alw^ays be heard, if ^h<* cliild is alive, at any rate 
after rqM'ated examinations, Hyth-nnuiios or tliit^k alxlorninal 
walls may prevent th(» sounds from \wmg transmitted to tlie ear. 
Tlie soumls are usually heard over tlie child's back. Therefon*, 
mnce left positions of the oeciput arc the most common, the hearts 
.*^>tmt!s are ^enei-ally to Ix^ heard on a line drawn from the uni- 
biUcus to the left anterior superior spine of the ilium. 

If they are not heanl in this n«gion the entire abdomen should 
be auseultated carefully. Changes in the pa^ition of the child may 
make the sounds audible at one time niul inamlible at another, so 
that, should there Ix' a failure to hear them, more than one exam- 
ination is to be made. Occasionally the child's position may h^ 
changed by manipulation for [)ur[ios4*s of auseultation, so tliat it-8 
Ijftek comes against ttie alxbnjinal j>arietes of the mother. Some 
ph\-sieians prefer diixrt auscultation, with the ear applied to the 
alj<lomen, to the mediate auscultation of the Btethos<;*ope, 

The binaural stethoscope is the best means for detecting the 
fetal heart -sou nils. Its mouth should Im moistened to do away 
with the noise generated by the slip[ung of the stetlioseope on tht^ 
tin. Generally the lightest ]>ossiIile pressure of the stethoscofie 
the skin is advisable, and to this end it is lx\st to let it rest by 
itoown weight and not to hokl it with the fingei-s. The lx*ating i»f 
the fetal heart (130 to 140 beats a minute) has l)een likened to the 
ticking of a watch under a pillow. To make the rliagnasis sun:*, 
the rate shouki be counted for a minute, and thus it is <lilTrrentiatrd 
from the maternal pidse, which is counted by the physician's 

iger on the mother*s radial artery. 

Tlie uterine souffle, or bruit so called, is an intermittent blowing 
gound sjTichronous with the patient's pul^^e. It oecurs not only 
in pregnancy but also in fibroids of the uterus and in other uterine 
and even ovarian tumors, and is probably due to incn7ise<l circula- 
tion in enlargeil blood-vessels. It is of no special diagnostic im- 
|»ortance. The noist« made by gas in the stomach and mtestines 
arc to be detected bv auscultation. 



J 



74 PHYSICAL EXAMINATION 

In cases of peritonitis, one may determine by tliis means whether 
the {xjristaltic movements of the intestines are still present. Fric- 
tion sounds made by the rubbing together of roughened surfaces 
of tumors and adjacent structures may sometimes be heard, also 
the murmur transmitted from an abdominal aneurysm. 

Mensuration is a means of determining the rate of growth of 
an abdominal tumor. Exact measurements are impracticable 
because of the varying state of the bowels as to distention or 
relaxation, and also because of the yielding nature of the tissues 
and the mobility of the tumors. Nevertheless, much may be 
learned, in cases of chronic enlargement of the abdomen, by making 
careful measurements at repeated examinations several weeks or 
months apart. These are made partly with a tape measure and 
partly with a pelvimeter, and, for purposes of comparison, all 
subsequent measurements should be made imder as nearly similar 
conditions as to time of day, time after menstruation, state of the 
bowels, etc., as possible. They should always be made with the 
patient in the same position and with all clothing loosened. Very 
light contact pressure with the tape or pelvimeter on the skin is best. 

The measurements to be taken are: — the greatest circumference; 
the circumference at the umbilicus; the distance from the cnsiform 
cartilage to the symphysis pubis; from the umbilicus to the an- 
terior superior spine of the ilium on each side; and the greatest 
diameter of the abdomen as measured with the pelvimeter, the 
patient standing, one point of the pelvimeter being placed over 
the most prominent portion of the abdomen, and the other over 
the spinous process of some definite counted sacral vertebra. 

Dr. Howard A. Kelly (^^ Medical GjTiecologj^" p. 17) has devised 
a method for making permanent gauze records of abdominal 
tumors and displaced viscera. The patient being in the dorsal 
position, the physician outlines the tumor and the landmarks, 
such as anterior superior spines of the ilia, margins of the ribs, 
symphysis, and umbilicus, on the skin of the abdomen with an 
aniline i>encil. If the skin does not take the pencil marks well, 
wet it with a little alcohol. Lay a plate of glass over the abdomen 
and on it place a piece of stiffened gauze (suisse, nainsook, or organ- 
die). The skin markings are visible through the glass. Reproduce 
them with a crayon pencil on the gauze. File away the gauze, 
labeled with the patient's name an(l the date, for future reference. 



76 PHYSICAL EXAMINATION 

The X-rays in Diagnosis. — The X-rays are of supplementary 
diagnostic value in detecting stone in the ureter or kidney, and in 
determining ptosis of the stomach and intestines when these organs 
are filled with bismuth in suspension, also the presence of bone in 
tumors, — conditions important for the g}Tiecologist to recognize. 
One skilled in the use of the Roentgen rays shouki be caUed in, as 
the neophyte is apt to be mislwi by the appearances s^^en in the 
photographic platee, and to put a wrong interpretation on their 
showings. 



CHAPTER \'II 
THE PHYSICAL EXAMINATION {Conclvded) 

III. The examination (ronriuded): 9. InstnimenL'^ ami Iheir use in 
duignosts, p. 77: General remiirkii. p 77, The uterine sonml, ji. 78: When 
to pmm it, p. 78; Methods of passing;, p. 7J^; Faets lu l»e detenninetl by the 
u«e of the sound, p. 80; Cantioris, ji. 84, The uterine protxs p, 84. Tlic 
uU-rine dressing forceps, p. 83. The uteri iie teiiaenhini, p. 8L The 
vulscllum, or double tenacnhini forcej^s. p. 8i. The vapinal s(M?eul*iin. p, 
85: The bivalve » or duc-khili i^jeeuluni, p. S3: The Xen^*hauer bivalve 
9(M*cu)um, the Ferj^uson s[M*cuiunijhe Simon s[it*enlum, and the Eflebf»hb 
speculum, p, 86; The Sims sfM'eulura, p. 87. The Hunter depressor, p. 
88, The Emmet curette foreejjs, p. 89, The ulerine curette, p. !10. 
Curetting, p. 90: Dangers of cure! ling, p. 93. Digital explfjratiou of the 
ut4?'rinc cavity, p. IH, Pelvimetry^ p. 95: Externa! or BaudeKKnue s 
eoiijugate diameter, p. Uil; The obli*jttc con jugate diameter. |>. 97; The 
trnnsversc diameter, p. 98: The tninsverse difinicter of the outlet, p, 98. 
The capacity of the pelvic cavity, p> 98; The obhijue diagonal diameters, 
p. 08. 

THE EXAMINATION (Concluded) 
9. Instruments and their Use in Diagncjsis 

In a fiiajority of g\Tit'c<>hjgif'al <lispases the diagnosis h tnadc* 
wilhout thr use of instrunicuts. They are not the most iinijortarit 
part of the physieian\s equipimmt. No matter how ingeiiiousty 
con^tructeil, and be they ever so well adapted to their U8(»8, instru- 
ments in the.se days ean not take the place of the (xlueated toueh. 
The physieian, jiartieularly t!ie American physician, with his native 
mechanical bent, aJthouKh nundful of the rt*vo]utionizing of 
gynct'ology by the sjieculuin (which his coiuitryrnan, J. Nhirion 
tilmSy K^ve to the world)^ should forswt^ar the wiles *»f the ijistru- 
HMnjt'iuaker anil devote liis attentiou to training his touch, leaving 
tn;^mfnent8 to the last. 

Tlie imnietliate followers of Sims and Eiiimi't W(»re so p1eas<^d 
irilh the newly disi-overtMl vaginal sptrulum and with titoir al»ility 
to ini^pect the va^a by it8 skillfid u^se, that they were quite eoiitt^nt 

77 



78 PHYSICAL EXAMINATION 

to rest their diagnoses of uterine disease on what they saw through 
the speculum. Hence it followed that for the time other means of 
investigation were slighted and only in recent years has the pro- 
fession escaped from the thrall of the speculum. 

Out of a number of instruments each examiner and operator 
will have his personal preference for those which seem best to 
serve his needs. My full kit of instruments is to be found in 
Chapter IV., page 28. 

The Uterine Sound. — The uterine soimd, although employed less 
and less as skill in the bimanual touch increases, is on the whole 
the most valuable of the instruments used in diag- 
^^ nosis. In the days of Peaslee, Simpson, and Sims, 
^ the use of the sound was much abused, as the other 

means of diagnosis had not been perfected at that 
time. The student was taught to pass the sound in 
nearly all cases of uterine disease, and, as aseptic 
methods were unknown, the results to the patient 
were too often disastrous. Not only was the sound 
passed into the uterine cavity, but malpositions of 
the uterus were forcibly corrected by this means, thus 
adding trauma to infection. At the present time the 
sound is employed to confirm a diagnosis made by the 
bimanual touch, and in certain rare conditions to make 
a diagnosis where the touch can not be used. 

The sound is to be preferred to the probe because 
the slightly larger end of the sound will slip over 
The Uterine irregularities in the mucous membrane lining the cavi- 
Sound. ties of the cervix and the body of the uterus, while 

the tip of a probe? will catch in them. A sound of 
small caliber made of flexible copper, with a knob at the distal end, 
one side of the handle Ixnng rough and the other smooth, should be 
chosen. One side of the handle is made rough so that the operator 
may be informed as to the direction taken by the point of the bent 
instrument when sounding a deep and tortuous uterine cavity or 
sinus. The? sound may be graduated in inches or centimeters, 
according to the pref(M-ence of the physician. It is easier to keep 
it ch^an if it has no not(»h(\s. The measurements are taken by mark- 
ing th(^ depth to which it has entered the uterus, by means of the 
finger tip held against the sound, or the dressing forceps grasping 



INSTRUMENTS AND THEIR USE 



70 



the sound at the external Of^ ami tlien, on withdrawing it, compar- 
ing the measurenients with a meavSurcMl si^ale on ihv inhh' on wliich 
tlie instruments are placet L 

Before pasi?ing the soiuid the vagina niu.si be eleanstnl in vvcry 

a^so. We do not know \\1mt baeterial gro^ih may h* j)restjnt in 
the vagina. As^umin^ that there an* no pathnt/f^nic nr;ranisms 
|>re*^:Tit under norninl eonditions, some are intruilyeed from the 
external gt^nitals in the course of the vaginal touch, which always 
preccnles the me of the sound. To idranse the vagina, swab it out 
several times with pledgets of absorlirni cotton hcltt in th** uterine 
clrcs?isting forceps arnl dii)i)e<l in a warm solution of creolin and 
water (one per cent). 

The soimd may bt* passed (1) bimanualJy^ the patient being in 
the dorsal position. To do this the |>h>^*^ician seizes a piece of 
abeorlx^nt cotton in the uterine dressing forceps held in his right 
hand, and carries it througli the warm creolin solution; now dc- 
preasmg the patient's [jcrineuin with his left fort^fiiiger hi the 
VBgtna, he swabs out the entire vagina, repeating tlie process 
several times. Ikying tlown the tiressing forceps hv, takes up the 
sound. The situation of the external os is determined with the 
tip of the left forefinger, and the knol>like end of the sound is 
CArriecI along the left forefinger until it enters the os. The furtlier 
nmuipulations are directeil by the niformation as to location, axis 

id sliajK? of the uterus, gainwl by tin* bimanual touch. It Is 
3mary to bend sliglitly tlie distal two inches of tlie soimd 
the roughened side of its handle. The sounti is held lightly 
fat the right hand ami allowe<l to slide in by its own weight. For- 
eihle raovement-s are al>snlytely contraindicated and unnecessary. 
Tlic* physician w^ho uses fcjrce then^by di^monstrates tliat he lias 
failed in liis bimanual touch. If the sounii does not pass readily 

i^hould he withdrawn and tlie end fx-nt at a different angle and 
pjntroduceth RemembtT that tht* barriers to the intrmluetion 
of the ^und are at the external and internal ora. The internal os 
is always closed except w4ien blocxl is passing out of the uterine 
cavity, after labor, or in certain i»athological states. 

In some cases where tht^ uterus is sharply flexinl, and when it is 

;h in the pelvis, the cervix may \)Q gnisixd with a tenaculum 
and ilrawn toward the \iilva to facilitate the intrtxluction of the 
aoimd. The tenaculum should be a single one, mtroducctl into tlie 




80 PHYSICAL EXAMINATION 

cervical canal, not a double tenaculum, which makes two holes in 
the cervix and may start a hemorrhage and cause pain. 

The sound may be passed (2) by sight. For this purpose the 
patient is in the dorsal, the Sims, or the knee-chest position. If 
in the dorsal position the bivalve speculum is introduced and the 
vagina cleansed. The cervix is steadied with the tenaculum and 
the sound mserted in the uterine cavity. If in the Sims position 
the Sims speculum is introduced, and the manipulations are as 
in the dorsal position. If in the knee-chest position, the Sims 
speculum is introduced and the vagina balloons with air, the uterus 
falling forward toward the abdomen. In this position it will be 
found necessary generally to seize the cei-vix with a tenaculum and 
raise it before the sound will enter. 

The uterine sound shows the depth and direction of the uterine 
canal, the size of the external and internal ora, the shape of the 
uterine cavity, situation of lacerations of the cervix, irregularities 
of the mucosa, the situation of the pedicle of a uterine polyp or 
submucous fibroid, the tonicity of the uterine walls, and, by biman- 
ual touch with the sound in the uterus and the hand on the 
abdomen, the thickness of the uterine walls. 

In passing the sound one measures thc^ distance from the ex- 
ternal OS to the internal os where the tip of the sound catches, and 
thus estimates the length of the cervical canal. The remaining 
distance from the internal os to the fundus gives the depth of the 
uterine cavity proper. In this way are distinguished the uterus 
of the little girl, the so-called infantile uterus with its long cervix 
and short body, and hypertrophic elongation of the cervix, an 
exaggeration of the infantile uterus; the atrophic uterus of old age 
with small body and shortened cervix; lactation atrophy, and the 
uterus deprived of its cervix by amputation. 

The uterine cavity, as a whole, is increased in size in pregnancy, 
subinvolution, hypertrophic elongation of the cervix, and new 
growths. It is diminished in atrophic conditions, — either failure 
of development or acquired atrophy, — ^in inversion, and in new for- 
mations encroaching on the cavity. 

In investigating the direction of the uterine canal it must be 
borne in mind that th(» cervical canal may extend in one direction 
while th(» uterin(» cavity is at >an angle to it, as in ant(»flexion and 
retroflexion. Inflammatory exudate or new growths in the neigh- 



INSTRUMENTS AND THEIR USE 



81 



J>orhood of the uterus^ by causing tlisplacemeiit, may alter tlie 
(lirection of the canal. 

Stenosis of the externul crs is (•onimon in certain forms of anti^ 
flexion where we find the isoealleil *Vpinhole os," in senile atrophy, 
and following imj:»ro|wrly performed o[>eration« on the cer\1x. 
Fal^ stenasis of the internal os h apparent in many cases of 
anteflexion, the sound passing when the utenis has l>een straight- 
ened by traction on the CiTvix with a tenacuhim. True stenosis 
Ls found after injuries of the internal os due to too vigorous curetting 
or to steaming; from inHannnation in the tissues in this neighbor- 
hood, as in cases of cancer of tlie cervical canal (adenocareinoma}; 
in senile atrophy; and it may fx* congenital, as in hematornetra. 

Both the intenial os and the external os may Ije eidarged in 
snibin volution and as a result of laceration. 

It is important to deteiTuimt whether the internal os also is 
lacerated in cases where there arv lacerations in the external os. 

\hi IB done by the sense of toucli comnumicatetl througli tlur 
nKJund, The situation and extent of laceration are determined 
partly by recognizing the landmarks in the mucosa of the cervical 
canal in the form of the arbor vita^ and by trjing to reconstruct 
the cervix in its original form by rolling the evert et! niges togethrr 
with tenacula, also by |>Iacing the sound over th<' arbor vita^ with 
il« tip at the middle of the fim<lus ami noting whether a lacemtion 
is on one or both sides of the sound, (Scv Chapter X III. , p. 21)9.) 
The m>imd gives a gcKxI idea of the shape and size lx>th of the 
cer\'ical canal and of the uterine cavity i)roper. 

The physician while passing the somid should keep in mind 
ahraj's the shape of the normal uterine cavity (see Figures 64, 67, 
ami 68, pp. 166, 171, 172), an isosceles triangle, having as IxiuiifU 
aries front wall, back wall, fundus, and internal os. There art* 
no mde walls, but in their place are the two fuiTOws forme<l by the 
meeting of the front and bark walls, beginning below at the internal 
ixi and ending above m the uriHce.s u{ the Fallopian tulx's. 

The internal os being relaxed or dilatcnl, the proi>erIy bent sound 
b peAm:Hl lightly and methodically over ante:*rior wall, posterior 
wall, fundus, and lateral furrows, dt^tecting fimgosities or inequal- 
iiies* in the mucosa, or a fH^dimeulateil growih. The last is very 
(Itifieult to do, and is not possible in all cases. It is surprising, 
however, how much may be learnts! by tmining the sound-touch. 



82 PHYSICAL EXAMINATION 

By sound-touch the firm, elastic resistance of the healthy uterus 
may be differentiated from the sclerosed tissues of subinvolution 
or the soft tissues of the septic uterus. 

With the sound in the uterus and the fingers on the abdomen or 
with a finger in the rectum, it is possible sometimes to estimate the 
thickness of the uterine walls. 

Cautions. — The greatest caution is to be exercised in passing 
the soimd in infcjctious cases, especially in gonorrhea, because the 
sound will carry the infective bacteria beyond the 
natural barriers at the external and internal ora. Also 
in cases of septicemia and advanced cancer, the sound 
should be used with circumspection because of the 
danger of perforation which is most ea^^ily made under 
these conditions, the uterine structure often being so 
soft as to offer practically no resistance to the pass- 
age of the soimd through it. Perforation occurs oc- 
casionally under such conditions in the hands of the 
most careful. Never pass the sound into the uterine 
cavity without fii^st asking the patient the date of her 
la^t menstruation. Make this an invariable rule, and, 
not forgetting the possibility of prevarication, and 
also having fresh in mind the result of the bimanual 
examination, — the invariable preciu^or of the use of 
any instrument, — you will avoid making that most 
serious of all gynecological mistakes, the sounding of 
the pregnant uterus. 
Fig. 22.— The misplaced uterus should never be replaced 
p ^, ^""^ with the sound, a practice much in v6gue twenty 
years ago. If the uterus is freely movable, not held 
by adhesions, it can always be replaced by bimanual manipulation 
together with traction by a tenaculum in the cervix, making use 
of one or more of the various gynecological positions. One at- 
tempt should not discourage. More favorable conditions may 
obtahi at another time. 

Besides its use in the uterus the sound may be used to investigate 

the bladdtT — its situation, as in prolapse of the uterus and in 

tumoi-s; also the situation of sensitive areas and the presence of 

stone or phosphatic deposits in the bladder. 

The Uterine Probe. — The uterme probe has the same uses as the 



INSTRUMENTS AND THETll USE 



83 



I 



surgical probe, and b(»sidt*s having a Imndle and a Jong shaft, it 
cnn be usc^d to investigate the interior of small uteiine ranaln, ainl 
niay l>e hmt to eonfonn to tortuous uterine 
interior.s or long amuses. The probe supple- 
fnerjtj!« the sound, but as an aid to diagnosis 
sshould not gfupplant it. 

The Uterine Dressing Forceps. — My pref- 
crenee for a thessin^ forct jis is one niatle 
on the seissors prinripit% as this seems best 
to supplement thu hand in uterine manipula- 
tions. The forcep'*^ known as Boxenian s, — ■ 
detaelmbk* l»lades with double eurve, catch, 
and aerrated jaws,— makes one of the most 
useful instmment8 known to 
gynecological art. With it we 
not only graqi pledgets of cot- 
ton with ^vlilch to wi|x* away 
I the discharges and cleanse the 

vagina, but also remove a bit 
of strmgy, tenacious discharge 
from the os uteri, or pit'^ci\s of 
tissue from tlie os or vagina for 
mieroscopie or bacteriological 
examination. 

By grasping with the for- 
ceps the uterine sound while 
in the uterus at a point 
where it proj(*cts from the 

external os, the de(>th of the uterine cavity is 
measured on a clean towel when the sound is with- 
drawn. 

The cur^'cs in the blades of the instrument permit 
of it-s entering the uterine cavity or a sinus while tin: 
hand w^hich holds it does not obstruct the operator's 
view. Being made on the scissors principle, levers 
of the first ckss with the fulcrum some distance 
fftim the jaws, one is 4ible often to open the jaws in a ca\ity 
(uterine cavity or sinus), after passing through a narrow opening 
(interoa] oe), or skin entrance, — something tliat a forceps made 



Fro. 23. — l^terine 
Dressing Forceps, 



Fig. 24.— 
Ulerifie Toil' 
aeulnm. 



84 



PHYSICAL EXAMINATION 



on the principle of the Sims uterine dressing forceps, levers of the 
third class, will not do. 

In an emergency the Bozeman dressing forceps may be used as 
a hemostatic forceps. The jaws may be wound with absorbent 
cotton and thus used to make applications to the interior of the 
uterus or a sinus, and the forceps may be used also to hold nitrate- 
of-silver pencils for cauterizing granulations. 

The Uterine Tenaculum. — This is to-day a neglected instrument. 
When used in days gone by to manipulate silver wire, the tenac- 
ulum was indispensable. The form of tenac- 
ulum devised by Emmet and Sims for shoul- 
dering silver wire is the best for general use — 
i,e,, one with a right-angled end, instead of a 
hook, for the reason that it holds the tissues at 
the point where !t is introduced, — is less likely 
to tear not only the tissues of the patient but 
the operator's finger, and it is more readily 
withdrawn from the tissues when desired. It 
should be introduced into diseased tissue when 
possible and does less damage and stays in 
place better in the hard resistant mucosa of the 
cervical canal than in the friable mucous mem- 
brane covering the vaginal portion of the cer- 
vix. 

Although the double tenaculum forceps, or 
vulsellum, holds more firmly than the single 
tenaculum, the single one makes but one punc- 
ture, causes less pain and no hemorrhage, and 
is to be preferred in the routine of examina- 
tions. 

Tenacula are of immense benefit in diag- 
nosis, in steadying and drawing down the cer- 
vix both for the bimanual examination and 
for inspection, in rolling together the lips of a torn cervix to estimate* 
the situation and extent of the tears, to reconstruct the lacerated 
perineum by hooking the landmarks and drawing them together, 
and in seizing and fixing a portion of cervical tissue to be removed 
for the purpose of microscopical diagnosis. The slender tenaculum 
does not bruise the tissues as does the tissue forceps. 




Fig. 25.— Vulsellum 
Forceps. 



TNSTRirMENTS AND THETH USE 



86 



The Vulsellum or Double Tenaculum Forceps*^ In rlioasing an 
iiif^trumont of this sort mw shoultl aim at having it not too heavy 
anfl yi't with strel ctiou^h to prevent the Wadt^s sprinw;in^ apart. 
The 8Q-calleil Aiueriean bullet forceps with two points, and having 
a check on one blade that prevents the blatles crossing, is excellent 
and most useful. Vulsella ma<le after the principle of Museaux^s 
foreeps (four points), or the French hea\T vulsella (four or more 
points), are us4»ful in the luoreellation of fibroid tumors and the 
rcrmoval of cancer, but have no place in diagnosis. The double 
teBaculuni forceps is useful in holdin;^ tfie cervix duritij^ dilatation 
when it is nccessar>^ to have a firmer bold than the single tenaculum 
will give, and in seizing ixxiunculated tumors in the vagina, al^o 
for holding and drjiwing down tlic uterus while practicing the 
bimanual touch to determine the n^lation of a tumor to tliis organ. 
(Sch: Figure I2tl) 

The Vaginal Speculum. — As has }yt\m said previoiusly, most of the 

diagnosis in uterine dis(»ast»s is rnadt* by the sense of touch. The 

va^nal s|>eeulum offers us a view of the vagina and vaginal portion 

I of the cervix. Of the multitude of difTen'Ut forms of specula to 

be had of the instrument makers, the most generally useful are the 

, bivalve anc' the Sims. The EdebohU- specnium with winght 

attached is for use in curetting an<l manipulations performed with 

the patient anei?thetized. In children a good view of the vagiTia 

■ may be obtainetl through a Kelly cystosrope, using as large a one 

ns will go through the vagina! introitus witliout injuring the hymen, 

the jmtient bnng in the knce-(*hest jjosition, 

Tfm Bivalve or DmkbiU Sf^eeidum. — There are many goo<i forms 

of this speculum on tlit' market. The writer prefers those called 

b3* the names of Brewi^r and Graves, h^-ause of their sirupli<*ity 

^and usefulness under varying conditions. Mf>re than one speculum 

[i^hould bt^ in every kit for the reason tliat vagime var>^ so in size. 

With a girl having a narrow vagina and a not easily dilatable h\mien, 

a ifiiiall s[K*culum is calletl for, whereas, for a woman ha\ing ex- 

Itciwvp injuric^s of the [ndvic floor ami perineum and lax and 

[ri»flunilant vaginal walls, a large sjx'cuhim is a necessity. The 

f|Milient is in the dorsal position. To introduce the bivalve speculum 

^be left forefinger is anointed with lubrichondrin and both valves 

of the .speculum are smeannl with it. The fon'finger is intrmluced 

mXo the vagina a^^ in making the digital examination, the perineum 



86 PHYSICAL EXAMINATION 

is depressed, and the speculum introduced, the slit between the 
blades being vertical. Before the speculum has reached its deepest 
point of entrance it is turned so that the short blade is above and 
the long blade behind. By means of the lever connected with the 
handle of the speculum the blades are separated until the cervix 
is engaged between their ends, then they are held in place by the 
set-screw on the handle. Some bivalve specula, such as the Graves, 
are provided with a second set-screw with which to hold the sepa- 
rated bases of the blades, thus increasing the spread of the specu- 
lum at the introitus vaginae, and adding to its usefuhiess in cases 
of roomy vagina). 

Care must be exercised, in handling the bivalve speculum, not to 
pinch folds of the vagina and the labia minora between the bases 
of the blades. This is most easy to do when the vagina is lax and 
the labia minora long. One objection to the bivalve speculum is 
that its blades cover both the anterior and posterior walls of the 
vagina, thereby obscuring them from view. This defect may be 
overcome in some cases by turning the speculum, first having 
loosened the lever holding the blades, so that the blades are on 
either side of the vagina. The cervix is to be brought into view, 
if it does not readily present, by hooking a tenaculum in the os and 
drawing the cervix downward. 

Tlie Neugebauer bivalve speculum and the Ferguson cylindrical 
speadum are used by some gynecologists. The latter covers the 
entire vagina and is of little value in diagnosis. The former re- 
quires much skill in handling to prevent pinching the vagina or 
labia, and when in place has no advantage over the duckbill specu- 
lum. 

There are various specula for use with the patient in the dorsal 
position that depress the perineum and posterior wall without 
covering the ant(»rior wall, such as 

The Simon specuhim, which is one-half of a Sims specuhmi. 
These specula are chiefly usi^ful in opiTative procedures where the 
patient is ant^sthetized and is not (tailed upon to endure the dis- 
comfort caused by prolonged traction on the perineum. For 
operative proc(M lures the simplest and best speculum of this class 
is die Edebohls speculum with a solid flattened weight weighmg 
about a pound and fitted with a hook, instead of the little 
pail usually sold with the speculum. The weight is made flat so 



IN-STRtTMENTS AND THEIR USE 



87 



Fio. 26. — Brewer Bivalve Speculum. 



that it cl<x*s not takr up ut^eful space at tlie inul of the ofM'ratmg 

table, A weiglit may be improvisixl <.*asily out of a piece of leacl 

pifx* lianimcn»tl Hat aiid per- 

foratetl to take a hook made 

out of a piece of stout iron 

wire. 

The Sirns Sjyeculum. — Tiiis, 
when given to the profession a 
generation ami a half ago by J. 
Marion Sims, transformed tlie 
art of gynecology, and i.s to I>e 
used only v^-ith the patient in 
the Sims position or in the 
kneo-ehe.st position. 

The orthodox met hew I of pass- 
ing the Sim? speculum is a.s fol- 
lows.— Tlie operator hol(L^ the 
^IXfulum by the unuse*l blade 
in his left hanil and places the 
well-anointL^l forefinger of thr right hand, along the blade which 
is to Ix* use^l, witli the pahnar surface of tin* fiiiger fitting tlie con- 
cavity and thi* tif) projecting jit^^t h^yontl the end of the bhide. 

The tip only of the finger entei's the 
vulvar cleft, and while the back of 
the forefinger protects the sensitive 
anterior wall of the vagina and in* 
troitus, the l)lade is pushed into the 
vagina Ijy pressure froru the thumb 
of the right hand on the imse of the 
blailc, the miu^erl jjlaile lx*ing at 
the same time transferreil from the 
opemtor^s left hand to tlie right 
hand of an assistant. 

Another and preferable way is to 

anoint the left forefinger as for a 

vaginal examination, except that 

the palmar as well as tin* ilorsal surface of the finger is smeareil 

with the lubrie^ant, then, hooking the finger about the blade of the 

speculum, anoint it from Imse to tip. Finally, pasis the same 



Flo. 27. — Orn^'es Bivalve Speculum, 



88 



PnySICAL EX.VMINATION 



fing<T over the vulvar floftj intrfKlurn its ii]\ into the vao:ina, and 
carrj" back tln^ pLrinrijin far cDOUgh to allow the tii) of the spcfu- 
him to enter. In pushing the specukini home the direction of the 
vagina Is to he home m niind^ its axis iKung not stimiij^tit u[)ward 
in the axis of the ]>atieet's body, but directed baekwartl toward 
the saernm* 

The use of the Sims i^pecnhmi necessitates an assistant, except 
for a most cursory examination. The assistant stands on the left 
side of the table at the patient*s baek and faces squarely the 
physician, who is f^eated in the ehair: with all the fingei-s of the 
left hand the assistant raises the laliium tnajus on the upper, right 
Bidi% holding it against the buttock witti the hand flat^ not with 
the ends of the fingers dug into the flesh. The assistant's left arm 
rests on the patient's right thigh. The right hand receives the 




FlO, 28. — Sims Speculum, 

unused blade of the speculum after the other blade has been settled 
in the profier place in the vagina. The simi>lest methotl of liolding 
the speculum, aufl the easiest for the novice to learn, is to grasp 
the unused blade with four fingers of the right hand, the palm of the 
hand iK-Ing upward, (See Fig, 11, ]>age o;!) 

With the speculum in jjosition air enters the vagina and the 
pelvie contents gravitate to^vard tlie ulidomen. Nothing liut the 
jjosterior wall of the vagina being eovei^ed, a nearly unobstructecl 
view of the vagina is afTordetl, Ry moving the speculum in or out 
or turning the tip from side to side, all parts of the vagina may be 
brought into view. If the vaginal walls an* redundant some sort, of 
a depressor will be found useful For tliis purpose the Ix'st instru- 
ment is 

The Hunter Depressor.— It shoidd have a flexil^le copper shank, 
and a large and a small end, and should U- silver-i>lated. With it 




J 



INSTRUMENTS AND THEIR USE 



m 



Fig. 29. — ^HuhUt VaginnJ I>eprcivsor, 



one pushes out of th(' field of vision the olHtrufting foUs of th** 

vagina, 1 lie Ilmiirr ili^pn^sHor has an advantage over the Sims 

ring-shapnl dt^prcssor in 

that its polishetl silv^er 

surface reflects Ught and 

therefore aids the 8|>e€U- 

luJTi in illunrniatinis: the 
^d«*i*p n^eessiss of tlie vagina. In many cases the uterine dress- 
ing foreejis, grasping a small piece of cotton, may be substituteil 
for the deprejs»sor. The smallest speculum which 
will give a good view should be chosen Ijccaitse 
the nmall instmment docs not stretch the hymen 
and introitus so much laterally, and thus a longer 
antero-i>ostcrior slit is ofx'nwl in which the smaller 
speculum may be moved about freely. It is a 
mistake to use a large speculum in the case of a 
tight h>inen or narmw vagina, because with it 
much less of the vagina can be seen and the patient 
is caused unnec(*ssary suffering. The opening into 
the vagina shoukl be oblong, not circular, and ad- 
ditional room is obtained only by carrying the 
]x>sterior wall of the vagina backward. 

Leaking into the vagina one confirms by Bight 
the infoniiation gained by touch and gains addi- 
tional data. The ruga? are seen, if i>resent, con- 
ilitions of inflammation are note*!, also the caliljer, 
length, and dilatability of the canal and abnormal* 
ities of shape and new growths. The character 
and amount of the discharge with it^ reaction, 
acid or alkaline; the cervix, its shape*, size, loca- 
tion, whetlier lacerated^ and if so, the situation 
and extc^it of the lacemtions as detei-mined hAh 
by sight and by use of the sound and tenaciila, 
also the cervical discharge, its character, amount, 
and reaction are all noted. Cover-glass specimens 

and cultures from the discharge may be made if necessary. 

The Emmet Curette Forceps.^ — This is one of the most valuable of 

the mi=trument^ used in diagiiasis. With it one removes pieces of 
jc from the uterine cavity for examination under the micro- 



FiG 30,— Em- 
kfft Curette For- 



90 PHYSICAL EXAMINATION 

scope. It has many advantages over the curette, especially in 

cases of pedunculated growths which often are not caught by the 

curette. This instrument can not damage the uterine walls, as it 

does nothing more than pinch the bits of tissue which project 

above the sm^ace of the endometrium. In selecting a curette 

forceps care should be exercised to have the jaws 

J^ ground true so that they fit accurately together. 

ll Many of the instruments on the market are abso- 

^ lutely useless because the jaws have rounded edges 

which do not fit accurately one to the other over 

their entire length. In consequence the tissue which 

is engaged between them slips out and is not pinched 

tightly and removed as it should be. 

Except after labor or abortion the cervical canal 
must be dilated to a moderate degree with Hanks 
dilators in order to admit the closed jaws of the for- 
ceps. When once in the uterine cavity the jaws are 
separated and then brought together again. Then 
they are removed from the uterus and the contents 
washed off in sterile water. The process is repeated 
imtil the anterior and posterior walls of the cavity 
have been gone over thoroughl)' and systematically. 

The Uterine Curette. — One curette is sufficient for 
all purposes of diagnosis. This is a sharp loop of 
medium size, the shaft of the instrument being made 
of flexible copper so that it may be made to conform 
to a bent uterine canal. Also with a flexible shaft 
the danger of doing damage by too forcible curetting 
is lessened. Following abortion or dehvery and when 
Uterine Cu- ^^cre is flowing, the curette, and often the curette 
rette. forceps also, may be introduced through the cervical 

canal without dilatation, except under such conditions 
where dilatation is necessary. Curetting should only rarely be 
performed without an anesthetic. 

Curetting. — Instruments Needed. — Sound, vulsellum forceps, Ede- 

bohls speculum, Hanks dilators, Wathen dilator, curette, curette 

forceps, two uterine applicators, Bozeman's uterine douche with 

irrigator bag and tube. 

The patient is anesthetized with ether, either preceded by nitrous 



INSTRUMENTS AND TIlErR I'SE 



91 



\'V. 



nf till* (jprrator. She 
on a Kelly pail with biit- 



Fia. 32.— Eilebohb 
Va^nal Spticulum. 



oxide or not, accorrling to the preferen 
is placcti in the lithotomy position 
toclcs at the tnige of the examining table, 
the legs Ix'ing held by an assisiaiit or by 
portable or fixed leg holilerf^. The binian- 
ual touch is practiced. The \iilva, vagi- 
na, and surrounding regions are \va^shed 
thoroughly with i^everal wa.shhigs of soap 
and hot water, then with alcohol, and final- 
ly with sterile water, Ob?er\'e that the 
bimanual touch is niaile before the wa*sh- 
iiig up. This is because the tactile sense 
18 less interfered with when the vaguia is 
lubricated by the natural .^XTctions, Af- 
ter irrigation and swabbing with alcohol, and especially with solu- 
lioDB of corrosive isubliniatc, the vagina is dry and clings to the 
finger, sometimes to such a degree that the scmsc of touch is very 
much bhmted. Sterile towels are placfnl about the 
field of operation and an Edebrjhls weighted specu- 
lum, previously sterilized with the other instru- 
ments^ is intrtxluced into th<i vagina. Tlie anterior 
lip of the cervix is seized with a double tenaculum 
forceps and the sound is passed. (For facts to be 
learned by the passing of the sound see page HO.) 
The cer\^ix is dilated by passing the graduateil 
Hanks metal dilatoi*s. These are safer than the 
bnmehed steel dilator, which, if carelessly used, 
makes rents in the uterine walls, more especially 
in the neigh borhoml of the internal os. These rents 
are not always recognized by the operator. 

If tlie cervix is rigid it is well to follow the Hanks 
dilatoi*s with a steel branched dilator. The Wathen 
ililator is one of the Ix^st of these. After it has been 
introduced the blades are to be separated by approx- 
imating the handles by manual iiressure, not by 
turning the set-screws, as is so often done. The 
reason for this is that when using the screw the operator can 
not judge of the force he employs, whereas, by manual pres- 
sure, he can e^imate it accurately. When sufficient power 



Via, 33.— 
HatilOi Uterioc 
Dilator. 



92 



Pm\SICAL EXAMINATION 



has l^een applied the screw is turned iiiitil the hiuidl(*s arr Ik'M 
hi place. ^Vfter the uterine iiuisele is tired the handles are brought 

a lit tit! nearer together and the serew 
takes up the slaek.^thus relieving the 
ojxTator's hands. Fifteen minutes are 
necessary for dilatation, more if the 
dilatation is to be excessive, as in cases 
where it is best to ins<:rt the finger into 
the uterine cavity for purjjose of ex- 
[ilnration. Dilatatioa being aeconi- 
plished, the curette is introduced and 
the walls of the uterine ea\'ity are gone 
over systematically, an- 
terior wall, posterior wall, 
lateral sulci, fumhis, and 
r*'gion of the internal 
OS. The eunite forcej^s 
always supplements the 
curette and many are the 
IHjly|>i wlii4'hhave escapeil 
the curette that are seize<l 
by tlie curette ff^ni^jj'"^^ 
The cuix*tting sliould \x\ 
stopped when the ciu^ette 
grates on the firmer sul>- 
in neons tissue of the uter- 
ine wall. The fettling im- 
parted to the curette is 
eharact(!ristic. The |>ieces 
of tissue ol)tainfHl are col- 
lected from the vagina on 
swabs of wet sterile* gauze 
held in the dressing for- 
ceps and transferred at oncc^ to a teo-per-cent formalin 
solution, in which they are pn\serv(Hl for the fiath- 
ologist. The uterine cavity is irrigated freely with 
hot sterile water or hot salt solution antl swal)lxnl 
dry with gauze wound around a uterine applicator. 



lid. 



31 — UjiTluti 



I'tuniif 



Fio. 35.— 
li o ii e m a n - 
Fril^seh UttT- 
inc Irrigalor. 

I^ozeman's 



uterine douche is as good as any for purposes of irrigaling the 



1 



INSTHUMENTS AND THEIR USE 



uterine cavity, though in ca.si*s of long and rigid ccmx, the 
Burragi^ uterine speeuhnu is useful both for irrigation and (nr 
bwabbing the uterine interior. For packing the uterine cavity 
with gauze, a pnx'edim.* sometimes nwessttated ui obstinate 
hemorrhage, this latter instrument is invahi- 
able, for the gauze Plips easily through the 
metal tube of the speeulum into the uter- 
ine cavity instead of clinging to the tissues 
of tlic cervical canal 

The vagina is now proteeted liy [^lacing a 
pledget of sterile gauze in the |)osterior vagina 
imder the cervix, and the uterine cavity 
id swabbfl out with a uterine applicator 
wound with gauze and dijjped in |>in*i' car- 

lx>lic acid. This s w a b h i n g 

serves a triple purpos<.*:^t an- 

tist^pticizes the uterine ca\ity, 

thus pro\iding for possible 

errors in technicjue; it mildly 

cauterizes the uterine hiterior, 

thus cheeking hemorrhage: and 

it destroys the httle islands of 

tissue which have been missed 

by the curette. By studying 

the interior of uteri whirh liave 

lieen removed by hysterectomy 

— a prt*vious; cun:*tting without 

hw*al>lnng having Ixhmi don<^it 

has lx*en tny experience to find 

that th<»n^ are nearly always 

presc*nt at least one or two liits 

of adventitious tissue left liehind by the curette. 
The fhtngerfi of Curetting. — These are: (1) per* 

foration of tlie uteins, a very considerable danger 
in iM^'ptic conflitions and after lalw^^r; (2) hemorrhage, especially 
after lalior or alxjrtion when the utirine sinusc^s are large; (3) the 
n*moval of t lie entire endometrium and submucous layer prevent- 
ing regeneration and causing the formation of scar tissue and 
fubfiequent sterility; and (4) t?eptie infection from the inocuJa- 



^ 



Fig. 36. — liurrap^ 
Uterine StK^ciilunt. 



Fia. 37.— 
Uterine Ap- 
pljcfttor. 



PHYSICAL EXAMINATION 



tion of the endonietriuni with septic matter already there or iii- 
troduccil from without. Perforation is avoided by using the great- 
est gentloness in <'urettiiig septic rases and in using the ciu-ette 
forceps or the finger iiisteail of the curette wherever possible. 

If hemorrhage oceurB, the uterine ca\ity is to be irrigatetl with 
very hot water (12CP F.), and, this faihng, it is to be packetl with 
gauze. For this purpose a Burrage uterine speculum and forked 

[jusher will t>e found 
most, useful. The re- 
moval of the entire 
endometrium and sub- 
nmeous layer is avoid- 
etl 113^ observing the di- 
rections already given, 
and the production of 
septic infection by olv 
serving strict asepsis 
and by not operating 
during acute attacks 
of t>e]vic inflarnma- 
tioiL 
(Tu^^iil^^ ^^^t^. UirfK^ifli^iCf^^ Digital Exploration of 

the Uterine Cavity, — 
This is practiced ordi- 
narily for complete in- 
vestigation in cases of 
doubt. The dilatation 
is effected by means of 
tlie Hanks dilators^ fol- 
lowed by the Wathen 
dilator. The Bossi uterine dilator or large stet^l rectal (hlators are 
useful for th(^ extreme stages of the dilatation. The bare finger 
sliould l>e employed for the exploration because thus the full ben- 
efit of tln^ tactile sense is to be obtained. In exceptional cases, 
thase with rigid cervices where dangrr of rupture of the tissue is 
great, a Miluable mettiod of exploring the uterine Ciivity is that 
described most fully in Dr Howard A, Kelly's ''Operative Gyne- 
cology/' Second Edition, AVJ, I., page 506. An anterior eolpotoniy 
is i>erformed, the transverse incision l>eing used. After the vagina 



Fig. 38. 



'//hr'1f\ 



-Transverse 
Cervix. 




Incision 



Anterior to 



k 



J 



INSTRUMENTS AND THEIH TSE 



95 



I 



and bladder have been Beparated from the uterus by blunt dis- 
8c*ction, the cervix is stc^adic^l by two \^g5elJa and the anterior lip 
of tile cervix is divided l>ct\vcf*n them with scissors to a point 
beyond the internal os. The digital exaruination of tin* uterine 
interior conipletnl, the divided uterine walls are brought together 
with sutures and the vagina is then replaeed and sutured. In my 
exj>erienfe, a eertaiu amount of preliminary dilatation of the cervix 
facilitates this opera- 



ii^ 



h 



vV^>A 



an 

■ tu 

I "' 

■ tei 



^^ 



lion. (See Figs. 38-li;) 

The remaining in- 
struments in the ex- 
amin<T*s kit, nanu-ly, 
thos4» for thf JTivesti- 
gation of tlie urethra, 
bladder, and lurtei's, 
and those for the nx- 
aminatit»n of the rec- 
tum, will Ije d(\<erilHMl 
in the succeeding rha[H 
tens devotcil to thesi^ 

l)jects. 

Pelvimetry. — The 
gynecologist is frt*- 
qucntly consulted by 
women who wisli to 
know whether they 
Fiavc any jx^lvic de- 
formity that would Ix' 
a hindmnfe to then- 
having cliiltlren, also 
by tlioee who are already pregnant with the same query, there- 
fore it sei*ms besi to deserihe the measurement of the pelvis. B. 
C. Hirst (** r)is<*ai^*s of Women/' p. 419) thinks that tleformed 
pelves occur in about seven per cent of the wliite women of large 
American cities, but that they are comparatively infrfMjuent among 
the upper clas«\s and iu thf* rural agricultural districts, while 
frwjuent among negrof^s. A general pnietitiouer in a city can 
hardly hope? to avoid seeing eases of pelvic deformity. For the 
many fonns of pelvic deformities the reader is advised to consult a 



hmW 



\yjf' 



Fig. m. 



-Incising the Ant^^riar 
tVrviv. i Kelly.) 



W^ali of thr 




1 



96 



PHYSICAL EXAMINATION 



9 



\K\ 



I 



^1 



modem tcxHx>ok on olistetrics. The commonest forms are simple 
flat pelvis, generally equally contracted pelvin {justominor}, and 
generally contrarted fiat i^elvis. Tht^se arc all due to faulty devel- 
opment of the skeleton. The other rarer forms are eaused by 
disease of the pel\dc bones and anomalies in the sacro-iliac and 
pubic joints. 

To practice pelvimetry successfully one must have a reliable 
tape measure and a pelvimeter. The latter is a large pair of 

calipei-s with a iseale divided into cen- 
timeters antl inches. The mea.sure- 
ments to be made are the antero- 
posterior iliameter of the superior 
strait, the capacity of the jx^lvic cav- 
ity, and the transv<*i'sr diameter of the 
jielvic outlet. In exceptional ais*\s of 
oblicjuely contracted pelvis it may he 
necessary to measure the obHiine di- 
a^^oiial diameters of the pelvic inlet. 
The patient must be prepared as for a 
\'aginal examination and should be in- 
spected f first in the standing position to 
note tlie posture^ shape of the back, 
and inclination of the pelvis. 

Exlemal or Baiuldocque's Confugate 
Diameter (8 inches^ or 20.5 centi- 
meters). ^()n inspecting the standing 
woman from Ix'hind, one sees in some 
cases, not in all, Miehaelis' rhomlxiid, 
a lozenge or diamontl-shai>cd surface 
on the skin at the l)ase of the spine. 
The four j joints making the diamonfl 
are: — on the sides, a ilepressio!i at each upper comer of the 
sacrum; at tlie bottom, tlie notch between the l>uttocks; and 
at the top, the depression over the spine of the fifth lumljar ver- 
tebra. If this ilepi-ession can not h^ sc*en, the spines of the 
vertebra* are felt l)y the finger from alx)ve downward until the 
last one is ivached. T\\v tiji of the pelvimeter, guided into place 
by the physician's finger, is jilaced in the depression just below 
the last spine. The other point of the f)elvimeter is placed on 



i 






Fm. 40.— TTtcrine Ca\-ity Laid 
Oiieii. (Kelly.) 



J 



INSTRUMENTS AND THEIR USE 



97 



'/^" 



"^i 



the anterior upper margin of the sympliyFis pubis, exactly in 
the middle line. Firm pressure is made and the reading on the 
scale of the pelvimeter i.H taken. The true conjugate can not he 
estimate*] accurately from the external conjugate because of the 
uneven thickness of the pi»Ivic 
fxines in difTerent individual^, 
and also txTaas<^ of the varying 
obli<juity of the pubic fjone. An 
extenial conjugate of 6^ inches, 
16 centimeter^, or under, means 
Furely an antero-[>ogterior con* 
traeted pelvis, anything over 8 
inches?^, 20.5 centimeters, is nor- 
mal or large. 

The ohlu/ue canptgaie diatfwter 
(5J inches, or 12.8 centimeters), 
or the distance imni the prom- 
ontorj' of the 8acrum to the 
under margin of the sjmjthysis 
pubi?^ may be measuretl b}- ex- 
amining the woman in thefloi-sal 
l>asitiom Two fingers of tlie k^ft 
hand are introduceil into the va- 
gina and the middle of the prom- 
ontory of the sacrum n*ache<i 
with the ti|> of the middie finger. 
Be* cart*ful not to mi^'take the las^t 
luml>ar for the first sacral ver- 
ti*bra and be* gentle and not too 
r»ind in performing this ma- 
nipulation, \\ ilh the tip of the 
forefinger of the right hand, 
mark the point at the base of 
the thumb of llje left hand 
touched by the lower edge of the symphysis. After the hand has 
been remove<i, tlie distance Ix'tween the tip of the middle finger 
and tlxis: point is measun*d by the tape measure. Subtract from 
this } of an inrli, or 1.75 centimeters (representing the thick- 
ness of the symphysis), to obtain the true conjugate. The 
7 



f 



Fio. 41. — Exploring I'teriiie Cavity 
with Fingtfr. (Kt^lly,) 



PHYSICAL EXAMINATION 



measurement of the normal true conjugate is 4f inches, or 11 
centimeters. 

T}ie transverse diameter (5f inches, or 13.5 centimeters). — ^This 
diameter is inferred from measurements of the iliac bones. The 
distance between the anterior superior spinous processes of the 
iHa in well-formed women is lOi inches, or 26 centimeters; the 
distance between the crests of the ilia at their widest points is 11^ 

niches, or 29 centimeters; the dis- 
tance between the trochanters is 
12J inches, or 31 centimeters. In 
making these measurements the 
patient is in the dorsal position, 
but with the thighs extended. 

The Transverse Diameter of tlie 
Outlet (4| inches, or 11 centime- 
ters) . — ^This is the distance betwet»n 
the tuberosities of the ischia and 
is measured with the patient in 
the lithotomy {)osition, the pelvi- 
meter being employed as in the 
other external measurements. 

The Capacity of the Pelvic Cav- 
ity. — This is an estimate fonned 
by vaginal examination with two 
fingers in the vagina. When the 
oblique conjugate is being measured the opportunity should be 
seized to palpate the interior of the pelvis and form an idea of its 
capacity, as well as a search made for abnormalities in the shape 
of new growths, old fractur(\s, caries, or necrosis. 

Tlie Oblique Diagonal Diameters (8J to 9J inches, or 22 to 23 
centimeters). — ^These are measured by the pelvimeter with the 
patient lying first on one side and then on the other. One end of 
the pelvimeter is placed on the j^osterior superior iliac spine on one 
side and on the anterior superior iliac spine on the other. The 
right obli(iue diagonal is generally a trifle longer than the left. 
The posterior superior spinous processes are often marked by 
distinct dimples on the woman \s back. 




Fio. 42. — The Pelvimeter. 



CHAPTER VIII 

:he investigation of the urethra, bladder, an!) 

URETERS 

Iiistnimerits ust^\, p> *M. 

Anatomy, |», HM), Tiie un^thni, p. KKI. The blfuliltT. [). li»L Luncl- 
uiiirkii in the bla*J<lrr» p. UH. The uivters, p, HJL 

ThecxmnitiuHon, p. 107, UathHtTization of the hlitthlcr, ]». lOH. Search- 
ing ihe urelhrii and the bladder, p. 1(*H, l)iref[ eiidnscupy and evstoseojiy 
irilh air dislendeil urt*thni and bhidder, p. I HK Uatheteriwition of Ihe 
uretefB* p. ll.>. Indirect cystosccjpy with waler disleiideil bhidder, p. 117. 
Cfaromocystoscopy, p. I ll>. 

Ix this chapter wr wnll consi<h'r only dirnrt uri'lhrosoopy and 
cv>to*4co[>y by nican.s of a sirn]jl(' tubc^ (tliu Kelly cy^sto^scopi*) anil 
n>flf*cted U^ht, a.s a moans for tin* inspection i>f the iirethi*a and 
bla(ldf*r, for it has bc^en found in the anther's exiierienee, to inirt 
sati^^facturiIy ttie ^}7ieeolopst 's n*f|uiretnents for diagnoms, Morc^ 
over, the nietho<I is easily learne<i and simpler than cystos^i-opy with 
a Nitze cystoscoix? or instrument of that class, by which an electric 
lamp IS introducefi into the water-dist funded bladder. As irnlirect, 
ek*ctric cysto«*copy la api>IiraK>le cx-casiunally where the air-ciis- 
tended b!a<lder methotl can not well be used, and as many physicians 
prefer it as a nK*tho<l of diapiosis, I have added as an appendix a 
de.*?cription of the stc|*s of tliis sort of eystascopy as I liave i*een it 
etnploycM.1 in competent hands. 



INSTRUMENTS USED 

Silver female catheter* long. 

KrlW meatus calibrator 

Kelly .st<M^I urethral ?<ounds, one set. 

Kelly cyt<toscopK?s, Nos. 8, 10, and 12, 

Kelly ureteral seajcher 



i 



100 THE URETHRA, BLADDER, AND URETERS 

Two Kelly ureteral catheters. 

Rubber bulb and tube for suction. 

Alligator bladder forceps. 

Uterine applicator. 

Sims speculum. 

Head mirror. 

To this list of instruments are added: 

A sterile ten-f^r-cent solution of cocaine hydrochlorate in water. 

A sterile four-per-cent solution of boric acid. 

Absorbent cotton. 

A sterile eight-ounce bottle with stopper. 

Two sterile two-ounce bottles with stoppers. 

A two-quart fountain syringe, and a 

Collapsible tube of lubrichondrin, or K-Y jelly. 

Not every woman who complains of urinary symptoms is to be 
subjected to a cystoscopic examination. For instance, frequency 
of micturition associated with early pregnancy, although not pre- 
cisely normal, generally represents increased congestion of the 
upper urethra and the neck of the bladder, due to the pregnant 
state, and is to be disregarded, unless the symptoms are so severe 
that they undermines the health by interfering with rest and sleej). 
Only when urinary symptoms are persistent as well as severe, are 
the urinary organs to be investigated. 

Before proceeding to the examination let us review the salient 
features of the anatomy of the urethra, bladder, and ureters. 



ANATOMY 

The Urethra. — The urethra is a membranous canal varying 
from an inch and a (quarter to an inch and a half in length 
(3 to 3.5 centimeters) extending from the meatus urinarius to 
the neck of the bladder. It lies under th(» arch of the pubes, 
its lower extremity being separated from the pubic bone by 
about four-tenths of an inch (1 centimeter). It is parallel with 
the vagina and is embedded in its wall, its course behig slightly 
curved, the concavity directed forward and upward. Its diame- 
ter when undilated is about a cjuarter of an inch (6 millimeters). 



ANATOMY 



101 



The meatus urinarius opens into the vestibule just alx)vc the open- 
ing of the vagina. 

In virgins the meatus m a vertical slit about a fifth nf an inch 
long, formed by two little lips which clos*^ the orifice and jiroteet 
it from infection. In old women the^e lips are 
lack Lug. Jj 

The waU of the urethra consisting of three ^ 

coats, muscular, erectile, and nuie<»us, is about onc^ 
fifth of an inch thick and is dilatable to a consider- 
able degree, the meatus lieiiig the most resistant 
part. It is not safe, liowever, to dilate the urethra 
beyond twice its normal diameter, i.e., beyon<^l half 
an inch (12 millimeters), becaiLse of 
the danger of permanent inconti- 
nence of urme. 

When the urethra is not distende<^l 
the mucous coat is throwTi into 
longitudinal folils, one of which, 
pla<:*t*d along the fif>or of the canal, 
R'sembles the venmiontanum in the 
male urethra. The canal is lineal 
with stratified epithelium, which be- 
comes transitional near the bladder. 
In the floor of the urethra are 
two little tubular glands, half an 
inch long anil about a thirty- 
second of an inch in diameter, 
placed ]ength"Wis(% with their ori- 
fices at the rnt*atus, just within or 
upon the labia uretlu-a^. These 
are Skene's glands. It is thought 
that the function of these glands 
is to secrete a hibricating mucus to protect the 
meatus from trauma during coitus. 

The Bladder.—TIie bladder, a musculo-mem- 
branous siic emlM*dded hi connective tissue, when 
quite empty and contracted is cui>shaped, and 
cm vertical median section its cavity, with the adjacent portion of 
the uiethra, presents a Y-shaped cleft, the stem of the Y corre- 



Fio. 43.— 
Silver Fvrnale 
ratheter. 



Pro. 44.— Kel 
'%f AfentUA Call 



102 



THE URETHIM, BLADDER. AND T^RETERS 



e^pomling to the iirethra. Whvn .slightly distenikMl ihv l>Ia<ltler 
has a roiDidod form and 18 stili (contained within the cavity of 
the pc^Ivis : when greatly disteiuled it is ovoid in shape, ris<"s 
into the abdoiiunal cavity^ and may reach as high a.s the 
umbi liens. Its capacity is al)out a pint. 

For pnrposes of desc Hfitioo the bladder may 
be tlivided into a }?yperior» an antero-inffrior, 
anil two lateral surfaces, also a base or fundns, 
and a summit or apex. 

The superior, or alwlorninal surface, is fnx* 
tow^ard the peritoneal cavity and is covered 
with peritoneum; the antero-inferior portion 
looks tow^anl the posterior surface of the s}in- 
physis pul)is and is uncovered by peritoneum; 
the lateral surfaces are covered by peiitoneum 
except in their lower portions where they come 
in contact with the liroad ligaments; the fuuflus 
or base of the blatUler is directed ilownwaRl aiul 
backw^ard antl is partly covered by jjeritoneum 
and partly uncovered. It is connected with the 
anterior a^fiect of the cervix and with tlie an- 
terior wall of the vagina liy areolar tissue* the 
union lMl\ve<'n the bladdei* ami vagina brnng 
closer than that betwc^en tlu^ bladd(U" and cer- 
vix. The upper portions of tht; bladder are more movable 
than the lower and when viewed through the cystoscope may 
be seen to move wdth respij^ation. 
The so-called neck of the bladder is the jioint of beginning 

of the urethra, 
^^ ^ true neck, as t 

g 1 tapering jiart. 

M 1 ^ tonic contrac- 

I .^^^ \ muscrular ^^ 

1 ^^^^^^ ft ^'^ 

\ ^^^^^IP J ^'-^' bladder wall at this point prevents the 

V^ ^^^^ Jf e^ape of urine. 

^^^^^^^^^ The bladder is composed of four coats: 

Fig* 46.— Kelly Evacuator. serous,nmscy!ar, submucous^ and mucous. 



Fig. 4r>.— The 
Kt'lly Doiilile- 
cntU'd Urethral 
Dilalor. 




AXATOMY 



103 



The serous coat is derivetl from the |>eritoiieuni and 
is therefore partial: the muscular t/oat is made up of 
three layera of unstrijK'd iiiusrular{ilin\ two of thoni 
Ix^ing lon^itiidbml, and on<', t'ireular in direction : the 
submucous coat is the alveolar tis.sue whieh connects 
the inuseular with the niucdus coat. The mucous coat 
is thin, smooth^ aiiti of a pale rose r-olor, and is tlirov^n 
into fokis or rug:e when the bladder is empty. There 
are no true glands in the mucous meintirane, 

Utndmarkfi in (he Bladder. — \\ lu-n the bladder is 
distended with air it forms a hollow sphere. The in- 
ternal orifice of the urethra or neck of the bladder is 
a deftnite landmark to be recognized by the obscTVer 
looking through the cyst(>sco|K? as the fij*st portion 
of mucous membrane wliich rolls into the kwiien of 
the cyj?tascope as its end is withtlrawTi through the 
uretlira. The ureteral orifices are two muiute open- 
ings situateil in small elevations of the mucous mem- 
brane of the blatMer (mons ur(*teris), an inch a|>art, 
one on each side of the median line ami each thrtv- 
(juartersof an inch (2 centimeters) from the internal 
orifice of tlit* urethra. These tlirec points mark out 
the trigone of the bladder. 

There is sometiTn**s seen the interureteric liga- 
ment, a distinct fold elevatefl al:K>ve the level of 
the surroumUng nuicosa comiecting the ureteral 
orifices. 

The l(X*ation of lesions in the hla<Ider is described 
by means of the^* lautlnmrks antl by the natural 
divisions of the bla<Ider alrea<ly given. 

The Ureters.— The un^ters are two cylinrlrical mem- 
branous tulxs lying in the loose connective tissue 
behind the aUlominal and jK-lvic peritoneum, about 
three-sixteenths of an inch (6 millimeters) in diameter 
and tw^elve inches (30 centimeters) long, extending 
from the [x^lvis of the kidneys to the bladder. The 
tngth of the ureters tlejx*nfls in some measure on the 
length of the trunk. A jjatient having a long trunk 
will have correspondingly long uif ters. Different 



-x- 



Fic. 48 — 
Kelly Ure- 
teral Cath- 
eter. 



104 



THE UHKTHRA, BLADDER, AND URETERS 



authorities give the length of the urt^ters all the way from ten to 
sixteen inches (25 to 40 centimeters). The left ureter is a little 
longer than the right bcH:ause of the liiglier position of the left 
kidney. The ureter is funnel-shaped as it leaves the pehds of the 
kidney and then the huuen has a diameter of an eighth of an 
inch (2 millimeters), imtil the ureter reaches its termination in 
the bladder wall, where there is a narrowing, which beeomes a 
complete closure when ttie bladder is distended. This closure 



FiQ. 49.— Kelly Cystoacope with Obturator. 

is effected by the oblique insertion of the ureter in the bladder 
wall, the mucosa and ant<'i'ior portion of the l)Iadder wall forming 
with the upper side of the ureter a wetlge-slmped valve, the ai3ex 
of the wedge Ix'ing at tlie ureteral orifice. 

The ureter lies on the psoas muscle throughout its abdonunal 
course, at the brim of the pelvis it lies on the conmion iliac 
artery. Withm the jx^vis it nms dovraward just outside the in- 
ternal iliac artery, and then, turning forward and crossing under 
the uterine artery, it passes half-way between the pelvic wall and 



ANATOMY 



105 



the cervix, at a distance of alwut half an 
ijich from the latt-er, under the Imse of the broar I 
ligament to the IJadder. The ureter is com- 
posed of three coatt?, fibrous, muscular, anil mu- 
cous. The fibi-ous coat h continuous with the 
caprnde of the kidney above and' is lost in the 
bladder wall Ix'low; the muscular coat of the 
ureter proper is made up of three laytTs: exter- 
nal, internal longitudinal, and middle ciiTular; the 
mucous coat issuionth and has a few longitudinal 
folib. It is continuous with tlie mucosa of the 
bladder below and the pelvis of the kidney 
above, and is comfjosed of several layers of cells. 

The ureters transmit the urine from the kid- 
ne>^ to the bladder intermittently l:>y means of 
peristaltic waves traveling the length of the 
ureter. Tlirough the cystoscope the urine may 
be seen to issue from the ureteral orifices in 
little spurts and the ureteral orifices may be 
seen to expand and contract, the spurts being 
more foiTihle and more frerjuent with greater 
activity of the kiilneys, the normal rate btnng 
all the way from one spurt every ten seconds 
to a spurt every sixty seconds. 

Obeer\^ations have lx»en reconhxl which tend to 
prove that the movements of the orifice are leas 
frecjiient when the kidney on tliat side is func- 
tionally inactive. Infection 

travels from the bladder up 
the ureter only when the 
valve-liko arrangement at 
the orifice in the bladder 
has been dei?troyed, or 
when infective material 
has been introduced into 
the ureter, as on a ureteral 
catheter or bougie, f^^^ 50,^Amgi,tor Biiwldcr Foro^^ 




Fro- ')L— Tlie Normal Filiniarr. Lai-1 Oprn frnm the* Front. (Kelly;) 



external f^rnilals are iiispfTtt*(l an<l a sharp lookout is excrcistMl for 
eviticnri^is of gonorrhea, for rczeniatoiis skin legions, or abnormali- 
ties of the meatus, 

Redjiess alx)ut the meatus antl the orifices of the glands of 
Skene and Bartholin, with the [rossihility of expresshig a drop 
or two of pus from the uretlira by stroking its coui-jsu tlirough 




THE EX.\MINAT10N 



107 



the wall of tlir vti^iiia, inakfH gonorrhnv rnfjst pn>l>ablc% iUm- 
orrhea. being BUPpec^twl, no iiistruiiieiit nhould lx> passed beyond 
the bladder neck for fear of carrvhi^ infection iiitn that nr^an. 

InsiHH'tion shows whether tln^ laljia urethne, which nornmlly 
close the nu*atu8 in vii*gins^ ar(^ in ap|josition or separatiHl; shows 
the pix'senre of a urethral caruncle or prolapse of the mueous 
nu-rnbrane of the urethm or a tumor in the urethra projecting 
through the meatus. Inspection also shows eczenm of the vulva 
caused by the urine of dialx^tes niellitus. 

Paljiation Iiy the left forefinger in the vatrina reveals thieketiintr 
of the urethra and tendrrTns> nt any poitit»n of its course, also a 



Fio- 52. — Urine ^urtinie from Ureteral Orifice, as Set*n through Cystt>srope. 

I Kfiorr.) 



suburethral abBcess or tumor, and the liinianual touch reveals 
thickening of the blatlder walls, a stone in the b!add(T. i>oiots of 
tenderaesas, a distend(*d bladtier, or a vesiecvvagina! hstula. P(»r- 
cusgion over the pulx'S delermines an area of dullness correspontling 
to a di.stended bladder. The bimanual touch niay reveal tenderness 
of the jx'lvic portion of the ureter or thickening: of the ureter in this 
part of its coui*se» or a stone in the ureter. 

To n^ach the upper portion of the j)elvic portion of the ureter the 
recto-atxloininal binianual touch is best. Thin an<l relaxeil alv 
ciominal walls art* a necessity for success in tliis field of uivesti^a- 
tion, although a thickened ureter niay be palpated in the lowest 
tiro inches of it^ coui'se by a digital vaginal examination, and, 
exceptionally, a thickened ureter may be seen as a ridge m the 



108 THE URETHRA, BLADDER, AND URETERS 

vaginal mucous membrane on speculum examination of the vagina. 
Palpation having furnished what information it will, the next step 
is the passage of the silver catheter. 

Catheterization. — I prefer a long catheter of small caliber, because 
it may be used both as a searcher of the urethra and bladder as 
well as a catheter. The meatus, vestibule, and inner surfaces of 
the nymphae are sponged with three or four pledgets of cotton 
soaked in sterile water or weak creolin solution, each pledget being 
thrown away as soon as it has been used once. That is, a piece of 
cotton is never dipped a second time in the water. Normally the 
urethra, as in the case of the vagina, except just inside the external 
opening, is free from bacteria. Well lubricated, the sterile catheter 
is passed gently into the bladder, the direction of the urethra being 
borne in mind, at first backward parallel with the axis of the 
vagina until the bladder neck is reached, and then forward. Care 
should be taken not to touch the outer end of the catheter before 
the urine is collected, and the lubricating should be done directly 
from the collapsible tube without the intervention of the physician's 
fingers. 

The urine from the bladder is collected in the sterile eight-ounce 
bottle for analysis, note being made of the character of the urine 
as it flows from the catheter, whether clear, cloudy, or bloody. 
Blood at the beginning indicates that its source is the ureter or kid- 
ney. Also whether the last part is cloudy, showing residual pus; 
and the force of the stream, increased in distended bladder and in 
cases of pressure on the bladder by tumors or straining, decreasetl 
in atonic bladder. Suprapubic pressure may ha necessary to 
empty such a bladder. 

Searching the Urethra and Bladder. — ^After the urine has been 
withdrawn the catheter is used as a searcher, the greatest gentleness 
being employed. The bladder walls are gone over systematically 
and points of tenderness noted. With a finger in the vagina and 
the searcher catheter in the bladder the thickness of the bladder 
wall at the base is estimated; a stone, foreign body, or phosphatic 
deposits are detected by a gritting sensation transmitted to the 
catheter, or, in the case of a stone, by a metallic click; sometimes 
a tumor is diagnosed in this way. In cases of cystitis it is not wise 
to sound the bladder at the same time that a cystoscopic examina- 
tion is to be made because the slightest trauma will cause bleeding. 



SEARCHING THE URETHRA AND BLADDER 



100 



The discharge of blocxl through the catheter at the end of eatheter- 
izatioa is a diagnostic sign of cystitis. 

If there is suspicion that tlie bladder is contracted, its capacity 
may l>e measures! by injecting with th<^ fountain-s>Tinge tul>e 
attached to the catlieter, wann, sterile, one-per-cent boric-aciil 
solution until the patient has a strong liesbx* to urinate* Tlien 
disconnect the syringe tutie and collect and measure the water 
issuing from the catheter* In cases of cystitis it is mse to irrigate 
thebladfier with l>oric-acid solution l3efore ending the examination. 
For this purpose the process just descril>ed is re{x*ated several times. 
It is to 1k^ noted that the catheter has not \wvn removed from the 
bladder since it was introduced, thus a minimum of trauma h 
inHiciecl on the uretlira and vesical neck. 

The bla<ider searching lifnng finished, the cat better is withdrawn 
slowly; clonic spasm of the I)[ailder walls is noted in some cases, 
indjeated by a druniining of the movable upper portion of the 
bla^lder on the less movable base. If the bladder is irritable or the 
muscular fibres ln*]K*rtroplnefl, the catheter is seizerl w^ith greater 
firmness at the bladder neck as it is withdrawn. 

When the eml of the catheter reaches the urethra one notes: 
pcjints of t^^ndemess, pouches in the mucous membrane or abnormal 
size in the lumen, also stricture, by no means rare, its situation and 
relative size. With a finger in the vagina anti the end of the 
catheter in the urt-tlu-a one determines the thickness of the walls of 
the uiTthra, the extent of an}* |)ouching of the mucous nieml>rane, 
due to rupturi' of the walls frorri trauma during ik4ivi*ry, and also 
diJilocation of the urethra downward. This is a common deformity 
iud one oft-en overlook*^ 1. To detect it the investigator observes 
wluHher the urethra Is in close relation with the under surface of 
the arch of the pulses as it should Ix' normally, or far away from it, 
ai» it is when dislocated. In cases of prolapse of the uterus the 
urt'thra, together with the Ijlaildcr, is conmionly dislocateil to a 
variable degree. Suppose the upper tliird of the urethra is dis- 
locatiHJ down wan I with the blad^ler. The catheter is passed into 
the urethra most gently until it meets the obstruction of the down- 
ward Jx*nd of the urethra. The point of the catheter is noted by 
[j&i]>ation by a finger iji the vagina and thus the situation of the 
beginnmg of the disI<x'ation is determininj. 

In the caae of procidentia, if the blatlder is dislocated a curved 



110 THE URETHRA, BLADDER, AND URETERS 

uterine sound is to be substituted for the catheter and the situation 
of its point, as felt by the finger, marks the lower limits of the 
bladder in the prolapsed mass. 

Having gained all the facts possible by the use of the catheter, 
the next proceeding is inspection of the urethra and bladder. 

Direct Endoscopy (Inspection of the Urethra), and Direct Cysto- 
scopy (Inspection of the Bladder). — The patient is in the dor- 
sal position. The bla<lder has bcTn emptied of urine. The 
tip of the meatus calibrator is passed mto the urethra and the 
size of the undilated meatus Ls read on the scale of the calibrator. 
Suppose it reads 6 millimeters. A No. 10 cystoscope may 
be used and the meatus must \yQ dilated a little. This should be 
done by gentle pressure on the conical calibrator and twisting it, 
care being taken that the lubrication is ample. If the tissues 
about the meatus prove to l)e rigid it is wise not to make all of the 
dilatation at one sitting, for the patient's confidence will be lost if 
she is hurt too much. If there is a stricture of the urethra it must 
be dilated with the double-c^nded steel dilators, and the dilatation 
should occupy s(»veral sittings. The meatus b(*mg stretched to 
10 millimeters without laceration or excessive pain to the patient, 
the next step is the cocainization of the urethra. Sometimes, if 
the meatus is sensitive, it will be found lx»st to use the cocaine 
before dilating the m(»atus. 

To cocainize the urethra w(»tthe terminal two inches of the uterine 
applicator and wrap it, using a sterile rubber glove to handle the 
cotton, with a thin lay(T of absorlx^nt cotton so that the diameter 
of the wrapped applicator is about three-sixteenths of an inch 
(4 millimeters). Soak this in stc^rile ten-per-cent cocaine solution 
gently ins(»rt the applicator into thi» un^thra, hold the cotton at 
the meatus with two fingers whik* the ap[)licator is withdrawn with 
the other hand, k»aving the cotton in the urethra. 

It is w(»ll not to pass the tip of the applicator beyond the neck 
of the bladder, because if tliL^ is done ardor urinse is likely to be 
evoked and, th(» cotton acting as a wick, urine will drip from the 
end projecting from th(^ meatus, thus diluting the cocaine and 
soiling the patient's clothing while she is bcnng put in the knee- 
chest position for tin* cystoscopy. 

A kne(ychest position, modified from that describcnl on page 
56, is the one commonly employed for cystoscopic examinations. 



DIRECT C\^STOSCOPy 



111 



In this case the thighs are not vertical as in the correct knee- 
chest position, the knees being nearer the chest. In very stout 
imtients and in certain operative cases the raiseil pelvis position 
(page oS) is eniployeii. By the time all the instruments are 
reacly» the room is darken*^!, antl the patient is well settled in the 
correct knee^'hest tx)sition (four or five minutes), the cocaine 
shoulil have produ<^ed sufficient anesthesia of the urethra to permit 
us to procetHl with the cystoseo])y. 

Ai-tificiai hght is necessary for eysto*^'0j>y. An electric light, 
gas light, or a kerosene lamp is to l>e chosen in tlie onler named. 
ITie ordinaiy sLxtfH'n-candle-power electric lamji is sufficient, a 



\\i 



Fm. 53. 



-ModififNi luiee-chi'st Position Usctl in CyBloaoopy, 

Buttorktt II) rbu MoiHfiwl Position. 



£r. la posiUon of 



thirty-two-canrlli^power lamp with a tin reflector is better. An 
argand burner nmkes the Ix^*^ ga.s light, but a Welslmch light is 
good. A kerosene lamp nmst have a circular burner so as to give 
a large flame. .Vny lamp should have the shortest possible stand so 
that the source of light may be a^ near to the patient's sacrum as 
I*j«st5ible. hi ordcT lliat the angle formed at the mirror on the opera- 
tor*s foreheail between the rays from the source of hght and the 
rtflected raj's going into the bladder may be as acute as possible. 
It should be rememlMT<*<l that the electric light, if held near the 
uncov€*re<l skin for any lengtli of time, will cause a serious bnni. 
If the patient is anesthctizcni this is a vcrj^ imjiortant fact to \year 
in mind. 



DIRECT (TSTl^SCOPY 



113 



Any fomi of illumination iiitrodu(*etl into the bladder oliHtruets 
the vieWj the wros for the lanij) cutting off a part of the lumen of 
the urethra, Ix^ides the n.-^k of buramg the bladder by the heat 
^generate*! by th** lamp. 

All being in readiness, the pleilget of cocaine-soaked cotton is 
remove*] fmm the uretlira and a welMubricated No. 10 eystoseoi>c 
with its obturator in place is passed into the urethra an*l blarlder 
If «ir does not enter the vagiua it in well to open the introitus 



ir" 



i^i: 



k 



J^JSs^ 



^^. 



/ 



b\\ 



^^*^. 



v^^ 



I FiO. 56. — Suction Apparatus in Uae for Hemoving Urine from Bladder (Kelly.) 



\'a^ie with one finger. If the bladdrr <!oi»s not balloon at onee, 
the silver catheter, previously ck-aneil and lubricated, is passed 
through the sphincter ani, thus lettmg air udo the rectum, and 
pc*rniitting the trigone of the bladder to come more into view 
through the cystoscope. 

Tlie operator sits on a high stool and looks through the cysto- 
itcope, which should be jiraetically horizontal if the patient is in the 
proper position. 



114 THE URETHRA, BLADDER, AND URETERS 

If urine has collected in the superior portion of the bladder, or 
if it collects during the examination, it is to be removed by the 
bent tube introduced through the cystoscope, suction bemg applied 
by means of the bulb and rubber tube attached to the tube in the 
bladder. The greatest care should be exercised to have the bulb 
and tubes sterile, so that infection may not be introduced, and to 
this end the bulb should be squeezed and held collapsed while the 
end of the tube is rinsed in sterile water before it is introduced. 
A modified chemical-laboratory wash-bottle may be used for re- 
moving the urine, as shown in figure 55. 

In cystoscopy with the patient in the elevated-pelvis position 
the collection of urine at the fundus of the bladder is much more 
troublesome than it is when the patient is in the knee-chest position, 
for in the latter position the urine falls into the capacious superior 
part of the bladder behind the pubes. 

The different landmarks of the bladder are sought for, the 
ureteral orifices inspected. Bits of tissue may be removed from 
ulcerated areas or new growths with the alligator forceps; cultures 
taken, or the ureters catheterized. Of the last, more shortly. 

A culture is taken by bending the handle of a sterile cotton- 
tipped uterine applicator so that the applicator will pass through 
the cystoscope without obstructing the view. After the desired 
area in the bladder has been swabbed with the cotton, the latter 
is drawn over the surface of the slant agar tube, hydrocele agar 
being used when gonococcus infection is suspected. 

To find the ureteral orifices first determine the situation of the 
internal opening of the urethra. This is done by noting the point 
at which the urethral mucous membrane begins to roll into the 
lumen of the speculum. The trigone, which is more injected than 
the rest of the bladder, is the space between the two ureteral 
orifices and the openhig of the urethra. It is small; therefore, the 
ureteral orifice is near at hand. If a V is marked on the external 
upper part of the cylinder of the cystoscope, with its point toward 
the bladder end and the sides of the V separated by an angle of 
thirty degrees, the ureteral orifice on one side may be found by 
bringing an arm of the V parallel with the axis of the urethra, when 
the cystoscope will point toward the ureteral orifice on the same 
side. The ureteral opening is a little slit situated on the mons 
ureteris, a slight eminence. 



CATHETERIZATION OF THE URETERS 



115 



Inspoc'tioii of the urethra, endoscopy, is jTractised a.^ the cystfv 
scope ii* vvithtlrawii. The neck of the bla^lder is i*ecognized as the 
first i>art. of the roUing-in rini of mucoys niembmne coming into the 
hinien of the cystosco|>e at^ the latter is bfnng withih-awn. Then in 
succession follow the diffen^nt portions of the urethra, the meatus 
being iaM. After the patient has been restored to the florsal 
position following cystoscopy in the knee-chest position, it is 
ess^'ntial to pass the silver catheter into {lie bladder to let out the 
air which has accumulated. If the physician rernernbers to do 
tWs the patient will \ye spared the ardor urinfc and the discomff»rt 
which attentl a distenfled bladder* OccasioTially the endoscope 
of Skene or the urethral bi^'alve speculum recommenrled by liiru 
are of grt^at service in viewing the interior of the urethra, esjjecially 
in investigating new growttis. These instruments have not been 
include*! in the list of instruments necessary for the investigation 
of the urethra, because the cystoscoi>e generally answei's eveiy 
pur|)06e of diagnosis, and simplicity of technicjue is aimed at in 
this Ix)ok. 

CatheterizatioQ of the Ureters,— If the bladder is the seat of 
infective inflammation the physician should debate seriously the 
ailvisability of eatheterizing the urett*rs, more especially if he has 
rt^ason to bcdieve that the ureters are not infected. If it is a 
question of unilateral gonm'tX'cus or tulx^rculous infection of kidney 
and ureter with erdargtnl kidney and thickened ureter, the diseased 
urettT shouli] U* catheterized, the healthy ureter should not b* 
cathet4.Tize<l, IxTause of the great danger of introducing septic 
matter into a sound ureter, the problem tjeing similar to that of 
[lapsing the catheter through the neck of tlie bladder in cases of 
gonon'hra of the* m*eihra, or of introducing instruments l:)eyond Ui«* 
internal os uteri in infections of tlie vagina and cervical canal. 
Nature has set up w^ell-defined Imrriers againvst infection, anrl the 
physician should he assured of good results to follow lx*fore breaking 
I hem down. 

The ureteral orifices arc found by tiepressing the handle of the 
eysto«cope and carrying it to one sitlc* while the tip is raised toward 
the patient s sacnini. The dimensions of the trigone are Ixmie in 
mind and the orifice shows in tlie j)roper ])lacr as a minute ojiening 
from witich a drop of urine spurts every few moments* The 
rapidity of the flow of uiiuc is dependent on the activity of the 



116 THE URETHRA, BLADDER, AND URETERS 

kidney, on the amount of fluids the patient has recently taken, 
and on the state of the nen'ous sj-stem. Sometimes it is advisable 
to regulate these factors before proceeding with a cystoscopy. Both 
orifices should be found before a catheter is passed, because in 
some cases the orifice may be displaced by uterine malpositions, by 
pelvic inflammation, or by other abnormalities of the pelvic organs. 

The ureteral orifice being found, the ureteral searcher is passed 
into it to make sure that it is the ureter and not a pocket in the 
mucous membrane. Then the catheter is passed and the cj-stoscope 
is withdrawn over it. The cystoscope ^ith its obturator in place 
is reintroduced beside the catheter and the opposite ureteral orifice 
is found and catheterized in similar fashion. 

Now the patient is gradually lowered into the dorsal position, 
the physician guarding the ends of the catheters as she moves. 





Fig. 56. — Nitze's Model of Ureter Cystoscope for Catheterizing Both Ureters. 

The sterile two-ounce bottles collect the urine from each ureter, 
the amount of urine and the time of flow being noted on each bottle 
as well as the ureter from which the urine came. Great care is to 
be taken to mark the bottles correctly, and to this end it is best 
to stick a gummed label on each bottle before the catheterization, 
and to mark the bottles at once after they are used. 

In exceptional cases something may be learned as to stone in 
the ureter or stricture of the ureter by passing ureteral bougies. 
Wax-tipped bougies have been used with success in diagnosticating 
stone in the kidney, but much skill, gained by long experience in 
this field, is necessary to produce results. 

Catheterization of the ureters with the patient in the elevated- 
pelvis position, a more convenient position when an anesthetic 
is used, is conducted much as in the kn(»e-chest position. The 
light is h(»l(l close to the patient's pulx^s and the operator stands 
looking downward, through the cystoscope to the trigone. When 



IXBTRKCT CYRTOSCOPY 



117 



llie oat lift el's mv in phivo the patient's pvlvU Ls lowered to 
the table. 

It should Ix^ remembererl that the eystoseopic appearances and 
the situation u{ tlie urctt^ml orifiees tire alterinl 
by iTialpositions and tumors of the utrTu.-^ ami 
by other pehie tuniorn. For uisf anee, in pro- 
lapse folds a|»pi'ar in tlie bladder mucosa after 
r(*|x)wsition of tJie uterus and the cystfX'ele. 

Indirect Cystoscopy with Water-Distended 
Bladder, — The instruments^ necessary are: — a 
Nit 2e cyhtoyieope with wire.s and electrie-light 
connection, a current controller and source of 
ek*ctricity, wuch as the strei^t current or a 
storage battery, irrigating bag and onc-per- 
cent boric-aeid solution, urethral cahbrator, 
urethral catheter, uterine applicator, absorf>- 
ent cotton, antl roraine. The bladder .should 
have a capacity of at least five omices and 
the Huid should be clear; if it is not, an irrigat- 
ing cystost'ope must be employed. The pa- 
tient is in the dorsal position ; the meatus urin- 
arius is dilated with the m^etliral calibrator 
(cocaine being used if necessary as described 
in direct cystoscopy, page 110) until it will 
admit a No. 25 French soiuid, the usual diarneter of most eysto- 
scopes. If there is a stricture of the uretlira it must be dilated. 
No bleeding should aecornpnny the intrmliiction of the cystoscope, 
hecau^ it will spoil the view^ in the blaiider. Before introtluring 
the eystoscope fill the blatlder with boric-acid solution and allow 
it to ran out until tlie water is clear, then from five to seven 
ounces are injected and the catheter withdra^\Ti, The eystoscope 
15 connected mth the source of light and the lamp tested. Then 
the current is turned off and the instniment is smeared witli 
lubrichondrin and introduce<l, care being taken to depress the 
faandJe as the curve passes the neck of the bladder. 

The following are the appearances of the bladder as seen through 
the eystoscope accortling to Casfx^r (**A Text-Book of Genito- 
urinary Diseases ''). The normal mucous membrane of the liladdfT 
varies from light yellow to pink, being redder at the base than in 



Fig. 57. — Current 
Controller for Ung with 
Electric C*ystoseope. 




118 THE URETHRA, BL-\DDER, AND I'RETERS 

other parts. In the course of a prolongcxl examination urine is 
poured out into the bladder l)y the un»ters and the color of the 
mucosa becomes redder because of the yellowness of the medium 
through which it is sc^n, also if the brightness of the light dimin- 
ishes the color becomes redder, therefore the light should be bright 

and white. The delicate ramifying 
blood-vessels, especially well marked 
at the fundus, are similar to the 
vessels sei»n with the ophthalmoscope 
at the fundus of the eye. Bundles of 
muscle filx^rs, parts of the detrasor 
v(\^ica% make little ridges in the blad- 
der walls, especially in the superior 

T.. ro r», jj Tju * t and lateral portions. Exaggerations 
Fig. 58.— Bladder Phantom for . , , , ^^ 

Practising Cystoscopy. of these ridges become the *' trabec- 

ular '' in the cases of hypertrophy of 
these muscles when increased work has been thrown upon 
them, as in stricture of the urethra. Between the trabecule 
may be diverticula, which look like deep excavations in the bladder 
wall. A shadow will cover a part of the circular field of vision if 
the cystoscope is withdrawn from the middle of the bladder. This 
is due to the fact that a part of the prism in the cystoscope is 
covered by the sphincter vesicie muscle. Carrying the beak of 
the instrument downward brmgs the base of the bladder into view, 
and pushing it a little backward and to one side brings the opposite 
ureteral elevation into the fiekl. If the ureteral eminence is 
watched for a little time it will Ix^ seen to swell up suddenly, make 
a con\ailsivc movement, and at the same time an eddy will be 
observed in the bladder fluid. This is the periodic discharge of 
urine. If the urine is discolored the bladder fluid will have to be 
renewcMl either l)y irrigation tlu-ough a catheter or an irrigating 
cystoscope. Often the urine from one ureter will be clear and from 
the other cloudy. 

This form of cystoscopy, like the direct form, should not be used 
in the presence of acute inflammation of the bladder and it can 
not be employed in the case of a contracted bladder. In chronic 
catarrhal cystitis the mucous membrane appears to be puffy, 
velvety, and red, and is coated with secretion. The vascular 
network is no longer visible, the surface of the bladder looking 



THR OMDCYSTaSCOPY 



119 



cloudy and dull Seak« ajid flakes cif secretion are foiintl floating 

fri*e in the fluid or on the bladder wall TulxTeuIous cystitis 

««hows noilules surrounded by a red border situated mostly on the 

flour of the bla<Mer, and in advanced case\^ distinct ulcers are 

visible. Tumors of the bladtler give especially good pictures with 

Jihia form of eysloscope and so tlo vesical ealcyli. Fon/ign Ixxlies 

re-an l>c distinguished and their size and shape determined, and a 

ureteral catheter, introduced into a ureter, may Ix* seen disajjpear- 

ling through the ureteral orifice and throwing a shallow below it on 

the l)ase of the bladder. 

To those who are interested in this form of cystoscopy the 
following books are recommendrn! : ** Die rystoskopie beira Wcibe/ ' 
Dr. Ricliard Knorr; 'Miandbnch der (Rystoskopie/' Dr. Leopold 

, i nat Cr. 



Fio, 5©.^Luya tlnne Separator It T>i\n<lc»» the RliulfJf^r into Halves hy 
a Hemovable Diaphragm and the Urine from Eacli Half h Ckjllected liy a 
8t^imil4; Tube. 

Cft8piT; '*Handatla.sder Cystoskopie/' Dr. OttoKneise; *^\ Hand- 
lx>ok of Clinieal Cyjstoseo|>y/* E. Hurry Fenwick. 

Cbiomocystoscopy. — CTironioeystost*opy is a metho4l of investigat- 
ing the functional capacity of each kidney that has Ijeen used 
abroad for the past s^ix }*ears with success. It con.'i^ist.s of cy»sto- 
scopy with water-filleil l>ladder. Fifteen minims of a five-per-eent 
aqueous Hotution of methylene blue are injectetl into the buttock. 
In five minuter, more or les.s in individual cases?, the urine is rendered 
blue and can be seen tlirough the cystosco|>c spurting from the 
mouths of the ureters. The urine* from the two uretei*s is coni- 
l>ared as regards the following points: — The interval before its 
appearance, the intensity of the color, the number of jets to the 
niinute, and the force of the jet. If one ureter eliminates dark 
blue urine while there is no trace of stain in the urine from the other 



120 THE URETHR-V BLADDER. AND URETERS 

kidnw, there may be ohstniction by a sUne in the ureter gi\Tng 
colorlffss urine, or compresaion of this ureter so that the passage of 
the urine is delayed, or such extensive destruction of the kidney 
tissue on this side that the stain has not been excreted. The 
methor] Ls said to obviate the necessity for ureteral catheterization 
in many ca.s'-s and to give a reliable indication of the functional 
cafiacity of each kidney, besides afifording a means of finding an 
otherwL*5e hidden ureteral orifice. 



CHAPTER IX 

THE INVESTIGATION OF THE RECTUM" 

Inspeelion of the ftnns, p. 1^1. Anakmiy of iJie rt^dinn, p. HI, Diplal 
examination, p. H3. ProclQsco|>\\ p, 1^4, Stretching the sfiliincler and 
i^ieculiUD examinaUoi] af the rectiiQi with an anestbeiic, p, Htl. 

The frequent associatinn of rectal and gjuceological affeetions 
makes the diagnosis of the fonner important, also symptoois in 
g>'neeologicaI disease are so often referred to the rectum that it 
becomes most necessary to eliminate rectal tUsease. 

Of course the rectum shoiUd be empty before an examination 
is made, an enema being given if there is any <loubt on this point, 
and it should be given always in cases where the rectum is to be 
investigateil with the (jroctoscope. In those eases in which there 
is protrusion of the bowel only at stool, the patient should go to 
the elos€'t Ix^fore the examination, 

Inq>ectioa of the Anus, — The best position for both visual and 
distal examination is the Sims position. Inspection of the anus 
may show external hemorrhoids, and internal hemorrhoids after 
the patient has just been to the chisct, external fistuUe, ulcerations, 
pin worms, al>sce8s, fissure, ainl skin diseases, such as eczema and 
venereal warts. If the hutto(*ks are separated by the hands and 
the patient bears down, a fissure may bo brought into vicnv. 

Some points in the diagnosis have been obtained alrcaviy from the 
vaginal examination. Tumors can be ruled out by the vagina] 
touch. The sphincter aiii is jiow everted by a finger in the vagina 
presBing the rectal wall out through the anus, thus affording an 
Opportunity for study and a search for hemorrhoids, i)oIyj»i, ulcera- 
tions, fissures, or fi^tulae. This procetiurc can not, however, be 
executed in virgins with unstretchrd perinea, a reasonal>le amount 
of injurj' or elasticity of the |)erineum being a necessity. 

Before taking up the digital examination let us review a few points 
to the anatomy and physiology of the n*c*tura. 

Anatomy of the Rectum. — The rectum is aliout eight mehes long, 
merguig above into the sigmoid flexure of the descending colon at 

121 



■ 



122 THE IX^ESTIGATIOX OF THE RECTUM 

the left sacra-iliac articulation, there being no distinct point of sepa- 
ration between the two. The upper portion, four inches long, is 
almost completely surroundcnl by peritoneum. The peritoneum 
is reflected from the anterior surface of the middle portion or 
ampulla, which is three inches long, at a point about two 
and a quarter inches from the anus to pass on to the posterior 
wall of the vagina. As the anterior and posterior walls of this 
part of the rectum are in apposition when it is not distended 
by feces or gases, it appears in sections as a transA'crse slit. 
The third portion, or anal canal, an inch long, is the part 
surrounded by the internal sphincter above and external 
sphincter below, and supported by the levatores ani muscles. 
When empty this part is seen in a vertical median section as a 
longitudinal slit. It is to be borne in mhid that the long axis of 
the canal of the anus is nearly horizontal when the patient is in the 
erect posture and is at approximately a right angle to the long axis 
of the two upper portions of the rectum, — ^therefore the anus dis- 
charges the fluid fecal contents not downward in the axis of the 
body, but backward. The soiled state of the rear boards of a coun- 
try pri\'y bears testimony to this fact in anatomy. When solid 
fecal masses arc passed the anal canal is taken up much as the cervix 
uteri is taken up during labor, and the feces are extruded dowTi- 
ward. This obliquity of the anal canal to the main lumen of the 
rectum lessens the din^'t strain on the sphincter made by accu- 
mulations of fecal matter and gases. 

The rectum is composed of four coats, — serous, muscular, areolar, 
and mucous. It is similar in structure to the rest of the large in- 
testine, except that the semilunar folds of the mucous membrane 
to be found higher up in the bowel are here strongly developed, so 
that they form shelves projecting into the lumen of the gut. These 
shelves or valves (valves of Houston) are generally three in number, 
two high up, are on the sides of the rectum, a third and the largest, 
is in front opposite the base of the bladder. When a fourth is 
present it is in the ampulla on the posterior wall about an inch 
above the anus. These valves are disposed alternately. WTien 
the rectum is empty they overlap each other so that it is difficult to 
pass a bougie or other foreign Ixxly by them. Their function is 
probably to support the weight of fecal matter and prevent it from 
impinging on the anus where its presence is sure to excite a desire 



DIGITAL EXAMINATION 



123 



for defoeation* Just aliove xlw hitemal sjjhineter the mucous 
membrane is thrown into i\mv or fmir longituciirial folds on each 
side, The^* are known as the columns of Morgagni. Between 
them are little jjockets, or valves. 

The vesi^ls of the rectum lie in the loose areolar tissue Ix^tween 
the muscular and mucous coats, and, receiving no support from the 
mascles, varicosity is favored. Moreover^ t!ie veins ]jien*i> tiie 
nmf^eular coat, run ^superficially in a longitudinal dircM^tion, and 
are apt to lye constricted when the muscle contmets; also there are 
no valves in the superior hemorrhoidal veins^ and hardened fecc*s 
are likely to press on them and stioke the Ijlood downward, away 
from the heart. The mucous membrane is thick and loosely con- 
nected to the muscular coat Ix^neath, thus favormg prolapse, 



Fio. GO. — Short Proetoscnpe. 



illy in the child, where the rectum is straighter than in the 



I 



The reflex contractions of the sphincter prevent healing of a 
ure and are a i?ource of pain. They als(t iirevent an ist-hio-rectal 
itecesa from closing and convert it into a fistula. Because over- 
developtnl by its acti\'ity in such cases, the sphincter is cspt*cially 
ig; therefore it nmeit. be thoroughly stretchcxl to the point of 
nporar}* paralysis b<^fore any o}>erative procedure can Ix^ under- 
taki.'Ti with tlie hojw of a successful outcome. 

Digital Examination*— I1i»* well-anoint rI left forefinger is passed 
into the anus, the direction Ix^ing first forward toward the vagma 
and ihtTi l>ackwanl. If the patient bt*ars down as the tip of the 
,gf>r |>aA^«es througli the anus, the spIiiiK'ter is i-elaxed and the 
ana] eanal is «traightene^I. Thus the discomfort is lessened while 
the finger is introduce<l gradually with a boring motion. The an- 




124 THE INVESTIGATION OF THE RECTUM 

tenor and side-walls of the ampulla are palpated. A lesion on the 
anterior wall is felt between the left forefinger in the rectum and 
the right forefinger in the vagina. The strength of the sphincter 
ani is estimated, spasm, due to long-continued irritation, areas of 
induration, ulceration, or narrowing of the caliber of the gut, and 
the presence of tumors are determined. A general smoothness and 
absence of folds indicates atony. 

The right foi-efinger, in like manner, is used to palpate the 
posterior wall of the ampulla. The presence of internal piles is 
very hard to diagnosticate by touch. The proctoscope must be 
used for these. In making the digital examination it is well to 
pass the unused fingers of the examining hand between the nates, 
or over the vulva and the thumb beside the vulva or between the 




Fig. 61. — Long Proctoscope. 

nates, for in this way a greater distance can be reached in the 
rectum than by shutting the unused fingers on the palm of the 
hand. If, after the digital examination, the diagnosis is still in 
doubt, the Kelly proctoscojx* should be used. 

Proctoscopy. — ^A good light, preferably an electric light and 
a head mirror, are necessan^ just as in cystoscopy. The patient is 
put in the knee-chest position. Something as to the condition of 
the anal canal may be leameil by the use of the smallest-size Sims 
vaginal speculum in the anus and some physicians report good 
results with it. Personally, I have not found it valuable as a 
means of diagnosis unless the sphincter has been first stret<;hed. 
The Sims rectal speculum is adapted only for use with the patient 
anesthetized. 

Two proctoscopes are sufficient for diagnostic purposes. The 
shorter one, tliree inches (7.5 centimeters) long by seven-eighths 



PROCTOSCOPY 



125 



and a 



inch (2,3 centimeters) in diameter, is passed first. It is thoroughly 
anointed and introduced slowly wliile the ijatient bears down. 
Thv phj^ician keeps in mind the direction of the anal canal and the 
rwtuin proper; the tii* of thv prrM:»tosc<>ije with its obturator in 
place is pointeil first downward toward the pubcs, then inwani in 
the axis of the botly after the sphincter has fx»en passed, and then 
upwartl toward the sacrum, RcinemlKT the situation nf the 
valves of the rectum ami work the tip of the proctoscope by them 
gradually. Removing the obtm-ator air rushes in, balloons the 
rectum, and permits a ^iew of the lower part of this organ. The 

[alligator forceps are useful to remove bits of feca! matter or to 
IPfcipe away secretion with cotton pledgets, or to obtain tissue for 
microecopic examination. As the proctoscope is withdrawn the 
internal and external sphincters arc inspectefl as they roll into the 
himen of the proc^toscoiH:*, The loii^rT proctoscope, five 
^B Fig. 62. — Long Alligator Forceps. 

half inches (14 centimeters) long by seven-eighths inch (2.3 centi- 
meters) in diameter, is of value to inspect the upi)er rectum. The 
sigmoidodcope is a dangerous instrument, for although by its use, 
in favorable cases, a glimpse of the sigmoid may be obtained , it 
b likely to injure tlie bowel. 

In introducing the longer proctoscope it is adWsable to remove 
the obturator after the spliincter has been passed and to carry the 
instrument higher in the ret^tum by sight. The semilunar valves 
caa be seen and avoided by the advancing edge of the prwtoscope. 
Remember that the empty re<'tum m normally contracted — that 
is to say, its walls are in ai>position— therefore^ this state must 
not be mistaken for stricture. The air sometimes dm^s not separate 
the wall*? of the upper rectum, although it dr>f*s those of the ami>ulla. 

The mucous membmrie of the n-cUmi is studdtnl by l>ranching 
Is and the openings of little glands may b<* seen. Inflamma- 
13S marked by a diffuse velvety injecteil api>earancc of the 




126 



THE INVESTIGATION OF THE RECTUM 



mucosa, together with the disappearance of the normal branching 
vessels; ulcerations arc easily distinguished, polypi may be seen 
hanging from the rectal wall, or the bleeding surface of a carcmoma 
may obstruct the lumen of the proctoscope. If there is stricture 
of the bowel because of syphilis, or cancer, a smaller proctoscope 
should be used. A large-sized Kelly cystoscope will often serve 
instead of a proctoscope in such cases, also in the examination of 
the rectum in children. 

Stretching the Sphincter and Speculum Examination of the Rectum. 
In exceptional cases it is necessary to give an anesthetic in order 
to make a complete diagnosis of rectal disease. In such an event, 
after the patient is thoroughly anesthetized she is placed in the 




Fig. 63. — Sims Rectal Speculum. 

Sims position ; the operator anoints lx)th thumbs and inserts them 
through the anus. By means of the fingers grasping both buttocks 
gt^ntlc but firm traction is made on the sphincter ani. A good deal 
of time should be devoted to the stretching of the sphincter, some 
fifteen minutes. Rapid and forcible stretching is very apt to 
result in rupture of the muscle followed by partial or complete 
permanent incontinence of feces or in fissure of the mucous 
membrane. Thorough stretching of the sphincter is an essential 
for any instrumentation of the rectum except proctoscopy. After 
the preliminary stretching the sphincter muscle is fixed between the 
thumb and forefinger of the left hand and successive portions of 
its periphery are stretched by the thumb and forefinger of the right 
hand. The Sims rectal spi^culum is pa'<s(Ml and light is reflected 
into the rectum by the head mirror, the alligator forceps and pled- 
gets of cotton being used to wipe away discharges and feces. 



(^IIAFrKR X. 

THE SIGNIFICANCE OF THE CHIEF SYMl^OMS OF 
PELVIC DISEASE. 



Dysnienorrliea. p. 1^8: Frequency, p, HH: Menstrual inolimena, p. 
MH. L DysriieTiorrhea a.^tKMalrd with fjelvir Ifsions, p. 1^1*: Con|^iiital 
nialfonnalions, ({etrojKisitiori with aiileHexion, Pelvic itiflamtiuiljoti* Filjroitk, 
[p. 1^. II. Dysmenorrhea where no [ii»lvic leskm can be found, p. ISO: 
Kc*urolic dysmenorrhea, Dysmetiorrhea due to poor general health, p, 130. 
Membranous dysmenorrhea, p. 1:50. 

Inlermenstrual pain, p. ]^H: Description, p. \M, Etiohi^y* p. L'ilt. 

Menorrhagia und Metrorrhfigia, p. I'U: L Cori.slihitronal eauj*es, p. !*?«>. 
11. Loca.1 causes, p. V.io: 1. The palient is n virj^iri, p. VM; Tabic of meii- 
iirrhii^ia and metrorrhj^fia in virgins, p. IJi?; ^i. T\w fiatient i^ not a virgin 
and (a) has never been jiregnant, fi. 187, (//) has fK-^^n pregnant » p. 138; (r) is 
pre^jtJit, pJIi8; Table uf nienorrhagia and metrorrhagia in married wonjen, 

Amenorrhea, p. lS9i L Primary amenorrhea, p. 1:13: Due to (a) Failure 
gn>wfh, j», ViM; (6) Atresia of ibe hymen or at the vagina, p. 110. i, 
!ijndary amenorrhea, p. 141 : Due to (a) Pregnancy and lacfalion, p, 141; 
\(b) Atrophy of the ovaries, jj. 14 h ('i Constitutional diseases, f>. 141: (*0 
Itxhausfion and s[i<K*k, \k 14^; (r) Hetentian of menses from acquired atresia 
i of the genital canal, p. 14^, 

Leucorrhea, p* 14JJ: Character of the di.s<^hHrge, p. 143; White dis- 
cliarge, p. 14.1; Yellow discharge, p. llSi Watery discharge, p. IHi FeM 
iijcharge* p, 144; Bk»ody distharge* p, 144* Occnrrefice of leucorrhca, ]>. 
144: Leticorrhen in childrtm. |). 144: I^euc-orrhea in virgins, p. 14."i; Ixnt- 
oorrhea in marrii.'<I women, p. IWx: I-je»ietirrhea in old women, p. 14tL 

Dyspitreunia, p. 14*1: I. Psychical can.ses. p. 14ti. ii. Anatonjica! 
causes, p. 140. 

Sterility, p. 147: Absalnte. p, 147: Secondary, p. 117: Facultailve, p, 
147, Sterility in the nnile, p. 148. Sterility in wumen, p. 148: Age as a 
factor, p. 148; Other factnrs. p. 14J), Auoniaties and iliseasesof the uterine 
origans* p. 150; Conditions of the uteri tie organs that cause interruption of 
|>regiiiinc*3r% p. 150, Constitutional dist*ascs and general causes* p. 151, 

V'esicjJ syniptoms, p. 151 : L Dystiria, p. 15 1 ; General catises and local 

causes, p. 15*?. 2, Ttxj frequent urinutjon, p. 15:*, 3. Incontinence of 

tirine. Enuresis, p. 154: Local causes, p. 154: (General eau.ses, p. 155; 

•focfuma! enuresis* p. 155. 4, Ketention of urine. Ischuria, p. 155, 5, 

Suppression of urine. Anuria, p. I5(k 

Rectal svmptoniH, p. 15ti: Pain, p, 156, Ilemorrhnge, p. 157. Rectal 
Itdchargv-, p. 157. Fecal aix-umulation, p, 157, DifFtcnIly in defecation, p. 
~158. Fratru2»iou from the anus, p. 158, Character of the feces, p. 158, 

127 



128 THE CHIEF SYMPTOMS OF PELVIC DISEASE 

Coccygodynia, p. 159: Etiology and pathology, p. 159. Symptoms, p. 
159. Diagnosis, p. 160. 

Pruritus vulvae, p. 160. Caused by: 1. Irritating discharges from the 
vagina or bladder, p. 160; 2. Diseases of the vulva, p. 161; 3. Neuroses, 
p. 161. 



DYSMENORRHEA 

The term dysmenorrhea (from ^w?, difficult, A*iyv, month, and 
i^ieiv^ to flow) signifies painful menstruation, and is used to 
define suffering of whatever kind associated with the performance 
of the function of menstruation. In spite of the many theories 
advanced to explain the occurrence of pain accompanying, preced- 
ing, or following the monthly flow, we are still ignorant of the cause. 
Authorities are not agreed as to the frequency of pain among 
normal women. Theoretically the woman should be conscious of 
menstruation only by the discharge of blood from the vulva; as 
a matter of fact a considerable proportion of women have some sort 
of discomfort. Marie Tobler (Monatsschr, fur Geburts, und Gyn., 
1905, Vol. XXII., p. 1) investigated this question in the case of 
one thousand and twenty women and found that twenty-six per 
cent had local pain, general discomfort, malaise, weakness, or 
mental disturbance at menstruation. Some writers place the 
percentage of local or general discomfort as high as sixty or seventy 
per cent of all women. It is to be remembered, however, that 
most of the data come from investigators who have to do with 
women afflicted with uterine disease and not with normal women. 

Memtrual molimina are the local and general disturbances that 
are supposed to be normal to menstruation; they are: — ^a certain 
amount of pain in the pelvis extending through the back and thighs, 
also nervous depression, resulting in lassitude, headache, nervous 
instability, and derangement of the function of different organs. 

Some of the last are: eye strain, skin eruptions — such as urticaria 
and acne, — pains in the joints, and loosening of the sacro-iliac 
joint in the case of sacro-iliac disease, and various sorts of "neu- 
ralgias.'' They are often spoken of as "reflex symptoms.'' Ex- 
aggeration of the menstrual molimina constitutes dysmenorrhea, 
although the term is more* often applied to the actual pain which 
is referred to the pelvis than to the more distant manifestations. 

Dysmenorrhea may be classified as of two sorts, (1) that associ- 



DYSMENOnUHEA 



129 



atccl with (Ipfinite dis*'oveml>Ie loj^ions of the uterine organs, iiwl 
(2) that in which no abni>nnality of thc>sc organs can be deter- 
niined. 

1. Dysmexohrhka Associatkd with Pelvic Lesions 



This includes clysTuenorrhea nectirring in the case of (1) Con- 
genital nialforinatinns of t!u* utfTiiit^ (Organs, (2) retroposition with 
anteflexion, (3) ix^Ivie inflammation, and (4) fibroids. 

I* Congenital Malformation of the Uterine Organs. — A woman 

'ha\ing an infantile uterus or a congenitally anteilexc^.! uterun is 

apt to sidTer with dysmenorrhea, so also, in the ea*se of atrt»sia of 

the vagina or of the uterus wIktu the ovaries are at the same time 

WeM develoi>ed, imin recurring at regular interv^als is apt to be a 

^constant symptom. 

2. Retroposition with Anteflexion. — Dysmenorrhea is the rule witli 
JthU affection, especially in tlu* case of the unfruitful. The jmin 

in thesf* casen generally Iw^gins with the ajipearanee of the fhnv, it 
Is cramp-hke, and is rr^lieve^l after the flow has bcTOUit* well estal> 
|j-she<l. Frequent and painful micturition is often associated with 
^this mali>osition, whate\'er the cause may be. 

This is a sort of uterus in which the s«>ealle<l obstntciive dyfsmen- 
orrhea was suppose**! by Marion Sim>? and his followers to occur. 
LThiis theory is that the escape of the menstrual disrliarges is impf*ded 
^by the flexing of the uterine canal Ijy a stenasis either of the internal 
or the external os, by an mtra-uterine jwlyp acting like a Irnll- 
valve, or by clots of blood. At the present time the best authori- 
ties* are agrn'^l t!iut artual (tbstnu'tion seldom exists. 

3. Pelvic Inflammation." Pelvic inflammation includes endomc^ 
tritis^ and also pelvic peritonitis, sal|>ingitis, ovaritis, and a eertain 

lount of cellulitis. In the acute stages of pelvic inflanmiatioti 
Ivfrnienorrhea is a fairly common sjinptoni — perhaps in from a 
d to a half of all ca^^s. In the chronic stages it causes uterine 
^ition and chronic emlonietritis, which art* more directly 
ausativT of painful menstruation. The \m\n is apt to antedate 
ftlie lx*ginning of tin* flow ancl lasts thnnigh the entire fM'riotl. 

4. Fibroids. — Dysmenorrhea is a fairly constant accompaniment 
of submucous and intcTstitial myomata. It is rare in the sut>- 

mtoneal 80rt» The size of the tumor bears no definite relation 
9 



130 THE CHIEF SYMPTOMS OF PELVIC DISEASE 

to the amount of the pain exfx^rieneed; often the pain is most 
severe in the case of vcTy small tumors. The pain in the uterus 
itself must be differentiated from the more or less constant pain 
due to pressure by large tumors on the surrounding nerves in the 
pelvis. The pain in the uterus, according to Kelly and CuUen 
(**Myomata of the Uterus"), is most severe at, or just before, the 
menstrual period. The pain from pressure is apt to be in the legs 
and feet and may be mistaken for rheumatism. 



II. Dysmenorrhea Where no PEL\ac Lesion Can be 

Found 

Dysmenorrhea often exists in women who, apparently, have 
perfectly normal uterine organs. In this event the painful men- 
struation is (1) neurotic, or (2) due to poor general health. 

1. Neurotic Dysmenorrhea. — Neurotic dysmenorrhea appears to 
be due to excessive sensitiveness of the endometrium. The uterine 
contractions occurring during menstruation cause abnormal pain, 
something like the after-pains of labor. The? formation of clots in 
the uterine cavity, exciting expulsive contractions and pain, has 
been assumed to be the cause in some cases, but there are no facts 
to substantiate this theory. Dysmenorrhea is often observed in 
cases of neurasthenia and sometimes in patients with this disease 
who previously had not had painful menses. The physician is 
often left in doubt which is cause and which effect in the investiga- 
tion of neurasthc^nia and dysmenorrhea. 

2. Dysmenorrhea Due to Poor General Health. — Dysmenorrhea is 
observed frequently in girls undcT tw(»nty who are the subjects of 
anemia or chlorosis. There are no satisfactory theories among the 
many that have been advancc^l to explain this association of men- 
strual suffering with these two diseas(\s. 

Membranous Dysmenorrhea. — Meml)ranous dysmenorrhea is 
characterized by severe cramp-like pains in the lower abdomen 
and back, resembling lalx)r pains, occurring at the time of men- 
struation and followed by the expulsion of a more or less incomplete 
cast of the cavity of the corpus uteri in the shape of a sac, triangular 
in form, gray in color, and having a rough surface. AVhen floated 



MEM BRAN0U8 D YSM ENORR HEA 



131 



in water and laid oj>en, the interior of the sac is smooth. With 
the aid of a niagnifyiiig gla^s this smooth surface is seen to be 
s^tiddnl with minute openings which represt*nt the mouths of the 
utricular glands. If the sac is n^asonaMy comjilete— it is self lorn 
entire— tile openings of tlie Fallopian tulK\s may Ix^ distinguished 
in the upix^r cohhts. The membrane Ls from one to three milli- 
meters thick and under the microsco|je shows much the apix^ar- 
ance of exudative interstitial en*lonietritis, although the patho- 
logical characteristics of the membrane are not constant; therefore 
membranous dysmenorrhea is not a tlefinite disease but a condition 
which exists in the* presence of different pathological processes. 

The etiolog^^ of this dist*ase is sluTnided in myste^^^ As far as 
known, endometritis precedes niend>ranous tlysnienorrhea in a 
large propoilion of cases. In certain castas menstruation is normal 
and regular until infection occurs following abortioii or labor: then 
membranous dysmenorrht'a develops hi the coui*se of a fi'W months. 
In another class of cases, many of them l>eing munarried wonjen, 
nienstruation is nonnal and regular anti the painful menstruation 
with the expulsion of a membrane tlevelops without any api>arent 
catise. Following the ex|>ulsion of the membrane there is generally 
a profuse* flow of blooth 

In making a diagnosis of meml>ranons dysmenorrhea we must 
exclude (a) df^ndual endometritis and {h) exfiJiativt* vaginitis. 

(a) In the case of decidual endometritis there is a history of 
pregnancy, also some of the signs of pregnancy or extra-uterine 

'pn^'gnancy should U* jiresi^it (see Chaptt^rs XXII and XIX). 
Ilemorrliage following the ex|)ulsion of the membrane, or parts of 
it, generally last« longer and is more profuse than is the case with 
m*'mbranous dysmenorrhea. The cast, of the uterine cax-ity is 
larg«*r ami more vascular than in the case of the membrane of dys- 
menorrhea, anil chorionic villi should bi* visible when the specimen 
is examined under the niist"rosco|M^. 

(b) Erfoliative lyaginitis may accompany membranous dysmen- 
orrhea, the exfoliation of thi* vagina Ijeiiig a pail, apparently, of 
the same pathological process which causes the casting off of the 
endometrium. Such an association, although authoritativt'ly 
n.'fK>rt(-Hl, must be considered as very rare, Kxfoliative vaginitis 
occurring as a result of inHammation or from treathig the vagina 
with frtrong caustics, such as nitrate of silver (see Chapter XX, page 



132 THE CHIEF SYMPTOMS OF PELVIC DISEASE 

364), is a not uncommon disease, and if the lining mucosa Is thro\iTi 
off at the time of a menstruation which is accompanieil by cramps, 
the physician must be able to distinguish between a cast from the 
vagina and one from the uterine cavity. 

A vaginal cast when floated in water does not present a tri- 
angular shape and no tubal openings are to be sei^n. However, as 
all casts are often exjK^lled in pieces, these features may be absent 
in both cases. On examining a vaginal cast with a magnifying 
glass it will be s(»en to have a surface that is relatively rough and 
there are no ojx^nings of glands in it. Microscopic examination 
shows it to be made up of stratified vaginal epithelium and the 
characteristic glandular structure of the endometrium is absent. 



HfTERMENSTRUAL PAIN 

Intermenstrual pain, or "Mittelschmerz,'' is the name given to 
pain similar to the pain of dysmenorrhea, occurring on a definite 
date lx»tween two menstrual periods, often midway between, but 
not always. 

This affection is by no means uncommon and every gynecologist 
of wide experience has met with several cases. Dr. H. A. Kelly 
(''Medical G\Tiecology '') has collectcxl sixty-four easels fi"om his own 
experience and the litcTature, and I will sunnnarize his conclusions 
from an analysis of these cases. 

As a rule intermenstmal pain do(»s not begin with the first 
menstmation, but is generally notcnl during the period of full sexual 
activity, that is, between the years of twenty and thirty-five. In 
a majority of cases it is ass(H*iatt»<l with sterility, but in a large 
propoi-tion of the child-lK'aring women who are the subjects of this 
pain, pregnancy scK^ms to stand in a causal reflation to the inter- 
menstrual j)ain. 

Thn^e cases of intermenstrual pain have Ix^en reported in which, 
pregnancy supervening, the pain ceasc^l entin^ly during pregnancy 
and during lactation, only to retui-n on the* reestablishment of 
menstruation. 

The pain ahvays occurs alK)ut the middle of the intermenstrual 
pericxl and extends into the second hnlf of it, and the date of the 
•iatermenstrual pain seems to tlepend on the date of the begumuig 



INTKHMENCTRFAL PAIN 



1.13 



of the following tTu*n8lrual perirMl and not nii tliai ai iUv jiivcrditi^ 
|M*ricNL 

Exact (lata a.s to tlie fH:Ki**i^i'lii *^f rrfi:iilar fiioti^tniation and the 
lx*giiiuiiig of the iiitornienstrual paiji shuithl Ix* unnk in vvory ca^e 
for rcTortl, The rharactcT of the pain varies in individual ca.«ies, 
it may he dull or it may be *slmrp; it is seldoin paroxy^inaL It is 
situates 1 in the pel vie rei^ion, just ai= in dy^^Illeno^rhea. The pain 
last^ from a few days, u[> to tht> entire time fmrn its beginiiing until 
the nejct men^ttnmtion. It genc^ially Iast.s three or four days. 

Internien.««trual |«iin may )x' pn^sent during all of a woman*s 
> OienstruaJ life. \\v have no assurance that it will cease short of 
Ihe menopause. It d^M^^ not seem to be associated witii dysmenor- 
rhea, although prcHisr* information on this point is lacking, hs^ it is 
on the que^stion of its assoriation witli regnlarity and irn'gularity 
of men?^ niation. There is a very great probal jility that many casc»s 
rated a-s im*gularity of [minful menstruation woidfl, if analyzed 
carefully, be fountl to Ix: eas<\s of intermenstrual pain. 

In a majority of eases of intermenstrual pain the suffering is 
aeconjjmnied by a vaginal discharge, either as a watery leueojrfiea, 
or a yellowish or bloo<l-stained discharge. Often, a uterine lesion, 
ach as endometritis, a p^»Iyp, or a sul>miieous fibroid will Ik* found 

explain the leueorrhea. As a rule, no definite relation has been 
efitablishtMl hetwet^n ix*Ivic lesions and intermenstrual {)ain. 

As regards the causation of this affeetion, Kelly is inelintMl to 
agn*c' with Sir \\'illiam Pric^stly. who first reiK)i'tetl fom* eases rjf the 
disorder in 1S71 iBrit. Med, Jour.^ Vol. II., ji. 6S3). His theory 
b that UJider normal contlitions previous to menstruation, one or 
fjoth ovarie** tx*eome (congested, tin* congestion |X'rsi.^ting tlu'ougli 
menstruation and for a few days after This congestion is attende*! 
by no signs. Under ahnonnal conditions, lx*causc of changes 
in the ovaries not undei-stoorl, the congestion b(*gins earli(T 
ihan usual and is attende<l by jx-hic pain. Therefore the j>ain 
IS relatic^n to the cortiing perirMl aiul not to that which has 
prpco<ied the pain. In the ea^es ol>scrvT'd clinically such a relation 
U found to exist. 

Physiciajis are urged to repuj*t ease's of intermenstrual jjain with 
exactness© so that tlata may lx> in hand as to this interc\sting and 
fic^gleeted affection. Besi<les the patient's age and soi'ial condition, 
the following points should Ih> nottxl: — (1) Day of the month on 



134 THE CHIEF SYMPTOMS OF PELVIC DISEASE 

which the last menstruation began. (2) Date at which intermen- 
strual pain began. (3) Date at which the following catamenia 
began. (4) Length of time the pain lasts, and its character. (5) 
Date when intermenstrual pain was first noted. (6) Full details 
of a normal menstruation, i.e., exact interval between beginning of 
each two catamenia, duration of the flow in days, amount of flow 
in napkins each day, occurrence of pain and leucorrhea. (7) 
Whether or not intermenstrual pain is attended by a vaginal dis- 
charge, and if so, its amount and character. (8) If a pelvic exam- 
ination has been made, note the findings. 



MENORRHAGIA AND METRORRHAGIA 

Menorrhagia (monthly bleeding, from Aty>e?, menses, and 
prjyvt'jvai^ to burst forth) an excessive loss of blood at the men- 
strual periods, and metrorrhagia (uterine bleeding, from y^yj'r^, 
womb, and fnfy^^vai^ to burst forth) a loss of blood independent 
of menstruation, are two terms which frequently can not be used 
with discrimination because the two conditions so often coexist. 
That is to say, a metrorrhagia becomes a menorrhagia when the 
menstrual period arrives, and menorrhagia, as in the case of a 
submucous fibroid, in the course of time becomes a metrorrhagia. 
Therefore it will Ik^ convenient to considcT the two symptoms 
together, Ix^aring in mind the fact that mc^riorrhagia may be due 
to constitutional dis(»ase, whereas metrorrhagia is always due to 
disease of th(^ pelvic organs. Menorrhayia is a relative term, for 
what is a moderate flow for one woman would be rated as excessive 
by another. Therefore, before pronouncing that menorrhagia 
exists in any given cas(», th(^ physician must inquire minutely as to 
the patient's normal habit of menstruation, getting the number of 
days that the flow lasts, and the number and size of the napkins 
used, and whether they are well saturated or not. As a* rule, 
under normal conditions, most of the flow occurs during the first 
two or three days. Find out whether this is the case. Supposing 
that it is, a loss of blood of a like amount, lasting through five or 
six days, would constitute m(*norrhagia. If the flow is increased 
during the normal mc^nstrual time it is one type of menorrhagia, 
and a menstruation unduly prolonged in point of time is another. 



MENORIlHAfJU AND METRORRILVOIA 



13S 



Only painstaking quest ioniiig, or the results of olxservalion by a 
nurse^ mil establisli the facts. 

In investigating a case of nieiion-hagia live constitutional causes 
ehould be considered fir^^t, then thi* local causes. Only the habit 

Pof excessive menstruation — not forf>npor two piTimls only ^should 
necessitate a diagnosis, and, particularly in the case of unmarried 

|girls and women, constitutional dis(>a*ses must bi* eliminated care- 
fully before procc»e<ling to local examination. The establishment of 
menstruation at puberty is frequently attended by menorrhagia 
for several perioils. Faniily tendencies are to be l^ome iu mind. 

_ln some families it is the habit for the women to flow freely, and in 
athers the reverse* liokLs true. 

I. CoNSTITirriONAL CaITSES OF MeNORRUAGIA 

The following l>li>o<l conditions are known to be attended by 
nienorrhagia: — hemophilia, (jurpura, scnirvy, leukemia, the uremia 
of nephritis, and sc^vere rholemia or jamidice. The various in- 
-feetious diseases, Ntich as small-j>ox, scarlet fever, cholera, tyfihoid 
rfever, influenza, and malajial fevvr, often have excessive menstrua- 
tion as a symptom. Menorrhagia is not imcommon in the early 
tagef^ of pulmonary phthisis, although amenorrhea is the rule in 
. disi*ast>. It also occurs iti syphilis and in the chronic poison- 
of alcohol, lead, or phosijliorus, anil in organic heart tliscase 
and in eirrhoeis of the liver. An excessive menstrual flow is apt 
to attend the initial stages of any acute constitutional disease. 
lleart disi*ase favors cliniacteric hemorrhage, — a feeble or an in- 
jfficient iieart making for pelvic congestion with consequent 
nienorrhagia or nietrorrhagia. 

IL TiOCAL Causes of Mknohrhagta and Metrorrhagia 



Having rule<l out the constitutional causes of menorrhagia, the 
phyHieian should make a careful vaginal examination in all cases of 
persistent uterine hemorrhage, whether oct^inTing at the menstrual 
periods or not. 

TTie local causes may be enunieratetl as follows: — 

Uterine ccmg^ion. 



136 THE CHIEF SYMPTOMS OF PELVIC DISEASE 

Endometritis. 

Polypi. 

Abortion. 

Extra-uterine pregnancy. 

Subinvolution of the uterus. 

Submucous fibroids. 

Cancer of the cervix. 

Cancer of the fundus. 

Sarcoma. 

Chorio-epithelioma. 

Inversion of the uterus. 

Backward displacements of the ut<?rus. 

Inflammation of the tubes and ovaries. 

Small cystic degeneration of the ovarie^s. 

Ovarian cyst with twisted pedicle. 

Arterio-sclerosis of the uterine blood-vessels. 

Vaginitis and injuries of the vulva and vagina. 

It may Ixj well here to point out the probable diagnosis to Ix* 
obtained from the patient's age, whether or not she is a virgin, or 
whether or not she has ever been pregnant. 

The following affections are common to the virgin, the married 
woman, and the multipara: — ovarian tumors, fibroids, and cancer 
and sarcoma. 

Arterio-sclerosis of the small blood-vessels of the uterus has been 
described by Henri Amal, Palmer Findley, and others. It is 
essentially a disease of the senile uterus, although cases have been 
reported in the uteri of women between thirty and forty years of 
age. As yet we do not know how often this condition, which seems 
to be not very uncommon, is the cause of hemorrhage. 

1. The patient is a virgin, and (a) is under the age of trventy-five. 
Increase^ in the amount of menstrual flow is most often due tout^^rine 
congestion, perhaps brought on by exposure, or over-exertion dur- 
ing a m(»nstrual period, or it may be due to a glandular polyp. In 
the latter cavse, the polyp generally produces metrorrhagia as well 
as menorrhagia, and thus we may distinguish between hemorrhage 
due to congestion and that due to a polyp. Uterine congestion is 
the direcrt cause of all uterine hemorrhage, the more remote causes, 
such as displacements and inflammation of the tubes and ovaries. 



MENORRHAGIA AXD METRORRHAniA 



137 



\mng many, Chronk- rndoiiit'tritis, foniuTly thoyjfj;ht to Ik* ilu- 
coimiion cause of utfTinr I4<*c*lin^» if« now n^gardinl as nhitivcly 
5, with the exception of the i>oly|>oicl and the hyperplastic varie- 
ties. 

(b) Menorrhagia may be due to backwaRl displacement of the 
uterus at any age Ix^fon^ the nienoi>au80. Fi^oni twenty-fi\'e to 
thirty-five ntrrine fil>roi<is of r^ylmiurous evohition are an inijiortant 
euuse of both menorrliagia and mt^trorrhagia. Cancer^ 4^^peeially 
cancer of the fiuidus^ is to l>e thought of a« a cause of metr(»rrhagia 
after the agt* of thirty-five, A w^ater\^ vaginal discharge accom- 
panies the flow vrry often in the case of cancer of the fuuihis; some- 
times abo in fibroids. 

The facta may l>e sunmiarized in the following table: — 



MENORRHAGIA AND Min^RORRIIAGIA IN VIRGINS, 



Age, MENouiiHAOLi, 

r ITterinc congestion. 
ITnder twenty-five. < Backward displacements. 



I 



Cofistitutional liiaeases. 



MBTRORRHAOtA. 



Utcnnt* i>olyp. 
I Rarely, submucous fibroid. 



L 



enty-fivo to 
forty. 



Uterine congestion, 
Endnfn«'trilia, 
Burkwurd < liHplafH'itiL'ntjs. 
SubniucoiLs fibri»id* 



'' Utt»rinp polyp. 
Submucous fibroid. 
Rarely, cancer or sarcomu of 
the botly of the utenis*. 



Over forty. h 



Submucous fibroiti 
Eridornetrilis, 
Uterine conieestion. 
^Backwuni di^pbctnncnts. 



Submucous fibroid. 

l^terinc polyp, 

CnmxT or sarcoum of tho 

bwly of the uterus. 
Rarely, cancer of the cervix. 



2. The patient is not a vixgin, and (a) has never beefi preijmtnL 
WTien a jiatient has Ix'^^n niarri«Hl a short time antl )s^ves a histon' 
of gonoeoccus infertion with |mriilent vaj^inal ilischar^^e ami smart- 
illgon urination, the probability is that if she lias nieiiorrha^ia she 
in suffcTing with gonorrheal endometritis and i>erha|)s with jiyosal- 
frinx hho. If gonoeoeeufi infertion is not present menorrliagia in 
such a patient pn)l)ably means uterine eongefciitiun clue to excessive 



138 THE CHIEF SYMPTOMS OF PELVIC DISEASE 

sexual intercourse. It may mean, however, a tear of the hymen 
from violent coitus, or a bleeding urethral caruncle. 

If there are any symptoms of pregnancy, such as a preexisting 
amenorrhea with sharp pain in one groin and tenesmus, irregular 
metrorrhagia might indicate extra-uterine pregnancy. In this 
case look for decidual membrane in the blood passed (see Chapter 
XIX., page 344), or it might mean an early abortion. The differen- 
tial diagnosis of these two conditions will be found in Chapter XXII., 
page 441. 

In the absence of the signs and symptoms referred to, metror- 
rhagia points to a uterine polyp. 

Menorrhagia becoming gradually metrorrhagia in a woman over 
thirty-five years of age suggests a submucous fibroid, and metror- 
rhagia occurring after forty, always should arouse suspicion of 
malignant disease; sterile married women and virgins being more 
prone to cancer of the body of the uterus than to cancer of the 
cervix, and parous married women to the latter. 

(6) The patient has been pregnant. If a pregnancy is not very 
distant in the past, metrorrhagia is probably due to subinvolution; 
if metrorrhagia also is pn^sent, there may be retained products of 
conception, or inversion. Metrorrhagia coming on six weeks or 
so after labor may mean chorio-epitholioma. If pregnancy was in 
the distant past, endometritis in various forms, utcjrine displace- 
ments, fibroids, or cancer of the cervix must Ix) thought of. Metror- 
rhagia beginning after the menopause has become well established 
almost invariably means cancer. 

(c) The patient is pregnant. Uterine hemorrhage beginning 
after one, two, or three months of amenorrhea, with the occurrence 
of some of the symptoms of pregnancy, points toward threatened 
abortion, and if regular rhythmic pains, like labor pains, are present 
also, to inevitable abortion. (See Chapter XXII., page 439.) 

Irregular hemorrhage, perhaps with the passage of decidual 
membrane, accompanied by pain in one? groin and bearing down, 
with any symptoms of pregnancy may mean extra-uterine preg- 
nancy. (See Chapter XIX., page 351.) 

In the later months of pregnancy hemorrhage may be due to 
placenta previa or, rarely, to carcinoma of the cervix. 

The following table summarizes the facts as regards uterine 
hemorrhage in married women: — 



PRIMARY AMENORRHEA 



139 



MENORRHAGIA AND METR0RRH.\G1A IN M.\RRIED WOMEN. 



hfuUiparip, 



Freynaney. 



PNgnane^, 



MSSORRBAQIA, 



"Uterino rongostirm. 
Inflmiimntion of tubes 

Hiid ovaritis. 
Submucous fibroid. 



f Sub-in vol uti on » 
< EntliiTnetritLs. 
I Hubniyfoiiji fibroid. 



( Rarely, menstruation 
( during pregnancy. 



Metrorrhagia. 

Uterim' polyp. 
Sub-muoous fibroid. 
Ext ra-uterint' [>regnaney 
RuiJtuft^d h>^ien* 
Cancer or sarcoma of the 
body of the u ten is. 
^Rarely, cancer of tlie eervnx. 

^ Retained products of concep- 
tion. 

Cancer of the rervix. 

Inversion. 

Senile endometritis. 

Chorio-<"pilhelioina. 

Rarely, cancer of the body of 
the uterus. 

^Threatened abortion. 

Inevitable abortion. 

Placenta pnevia. 

Extni'Ulerine pregnancy. 
^ Rarely, cancer of the cervix. 



AMENORR^A 



Imemorrhea, or absence of the nHmstnial flow (from «, privative, 
MVs month, and /J/£f>, to flow), may be* elaNsifinl as follows: — (1) 
Priraan' amenorrhea, or emansio mcnsiuin, in which menstruation 
has failed to appear at the usual age; and (2) secondary amen- 
orrhea, or suppressio mensium, in w'hieh mensiruation has ceA^fnl 
after it han hotm estalilished. 

I. Primary Amenorrhea.^ Primary amenorrhea is due to (a) 

lure of grouih of the uterine organs^, perhaps coincident witii 

rk of general l)oiliIy growth, |XTha|>s not, or to (h) atresia of the 

hymen or of the vagina. The last condition, called cryplomenorrhea, 

is»» gftrictly speaking, not amenon*hea at all, but a retention of nien- 

trual fluid. As we are considering the symt>toni of alisence of 

^memftruation, it is convenient to include cryptomenorrhea in this 

place. 

(a) Failure of Growth, — A girl ha\4ng a stimtefi physicjue may 
hskve tardy growth of the uterine organs also, and menstruation 



140 THE CHIEF SYMPTOMS OF PELVIC DISEASE 

may appear later than normal. This, however, is not so often the 
ease as it is to find a gocxl physicjiu^ and abnormal uterus and 
ovaries. The uterus which exhibits faults of development, such 
as utenis dideli)hys, uterus bicomis, and uterus bipartitus (see 
Chapter XIII., page 199), does not ordinarily have amenorrhea as 
a symptom, although rudimentary uterus, when associated with 
atresia of the vagina, generally does. Arrests of growth, on the 
other hand, — infantile uterus and congenital atrophy of the uterus, 
— are commonly attend(»d by amenorrhc^a. Infantile utenis is a 
relatively common condition. The uterus is narrow in proportion 
to its length, has a long cervix and a short body, and is situated 
w-ell back and high in tlie pelvis at the end of a long vagina. The 
cervix is conical and anteflexcMl, and the os a "pin-hole os.'' The 
patient's figure, breasts, hair, and voice are g(*nerally of the fem- 
inine type. Congenital atrophy of the uterus is a rare condition. 
Here all the dimensions of the utcTus are reduced while the normal 
proportions are retained. The condition has been found in dwarfs 
and cretins, and in early tuberculosis and chlorosis. It is supposeil 
that in these cases the uterus attained a proper growth to the 
virgin tyj)e, and that atrophy followed. 

Both of these conditions are gen(Tally associated with anomalies 
of the ovaries. (Sec Chapter XML, p. 285.) Congenital absence 
of both ovaries is extrenu^ly rare. It is of course accompanicn^l by 
absolute am(»norrhea. Abscaice of one ovary does not affect men- 
struation. Faulty growth of the ovari(\s accompanies both infantile 
uterus and rudimentary uterus. The ovaries are small and amen- 
orrh(^a may exist. 

(6) Atresia of the Hymenj or of the Vagina, — Cryptomenorrhea 
may be caused by imperforate hymen (see Chapter XXL, page 396), or 
by th(* diffen^nt varieties of atresia of the vagina (see Chapter XX., 
pag(\s 357, 359). In these cases th(^ ovaries are functionally active. 
Menstrual molimina an^ pres(^nt and may be attended by severe 
cramj) pains, and then^ may b(^ vicarious menstruation from the 
nose or other mucous-membran(*-lined cavities. The menstrual 
fluid collects behind the obstruction, which may be situated any- 
wh(T(^ from the hynu^n to the internal os, though it is usually in the 
vagina, and by distending first the vagina, then the uterus, and 
finally the tubes, causes the conditions known as hematocolpos, 
hematometra, and hematosalpinx, respectively. 



SECONDARY AMENORRHEA 



141 



Tlie pfttipnt, who has pa.S8<xl the usual turio fur pyl^erty, pro- 
sen is a normal figure and ha.s normal feniiniuo l^reajsts, hair, and 
voico. She roinplains ot aliscnt'e of itieustriiation and suffers with 
menstrua) niolimina — generally j^-vere cramps in the lower ab* 
(lomen. 

2. Secondary Amenorrhea*— Tin • following cauKC^ be.sides the 
menofiausi' may \n' eruiUKTatrd as afroimtirig for the et^ssation of 
menstniation after it haj^ k-en eytablishcHl; — (a) preguaney and 
lactation, (6) atrophy of the ovaries, (c) constitutional diseases, 
((/) exhaustion anrl shoek» and (e) retention of menses from 
acquired atresia of the genital eanah Cessation of menstruation 
nmy h)e temporary or pi'rmnnent; if the latter, it eonstitutes the 
menopause. 

(a) f^refjtmficy nmi LavintiufL — Pn-gnanry nmst b<* eonsidi^red 
the chief cause of amenorrhea and the physieian will du well to 
bear this constantly m niiml, even in the cases where tiie prnlmhility 
of it6 btnng present seems to bi» snialh It is to bo rememlx^ed that 
menstruation may f>eeasionaIly oerur iluring pregnancy (see Cha|> 
tcr XXIL, page 419). The menses are usually absent dming 
lactation » thougli not always. Prolonged lactation may indtiec 
lactation atrophy of the ovaries with cons(H|ucnt amennrrhca. 

{h) Atrophy of the Oi an e.v.— Not much is known alx»ut the eon- 
tlitions which cause atro[)liy of the ovaries. When atrophy has 
taken place the oophoron of the ovary, the egg-lx'aring zone, u? 
smaller and harder than normal, and becomes transformed into a 
layer of dense* fibrous tissue. 

Ovarian atrophy lias been reported in women who have nursed 
their childn*n a veiy long time, aiifl also in tlie following diseases: — 
the exanthemata, myxiiiema, marked anemia, arnl diabetes. 
We are justifR^l in suiJi»o.sing that ecKsation of function of the 
m'aiim iJ* the direct cause of amenorrhea ui the 

(r) Con^iilulionnl O/.v^^ri.'^e^f,— Wheth<*r denif)nstrable degenera- 
tive tij^ue changes occur onlinarily when amenorrhea is prestiit we 
«lo not know. There is no doubt tFiat the ovaries show a decrease 
iti siate imder such conditions. 

Sud<lenly acciuirni ol>c»sity is (jften attend^tl by amenorrhea, so 
also are the early stitges of pulmonary |»hthisis. In the hornier 
caf*c* it is ap|>arently du<' to anemia and over-nutrition, an*l in the 
tatter to anemia and malnutrition* Other instances of tlie latter 



142 THE CHIEF. SYMPTOMS OF PELVIC DISEASE 

cause arc: tuberculosis of the kidney, diabetes, chronic nephritis, 
malaria, chronic mercury, lead, or alcohol poisoning, leukemia, and 
the morphine habit. 

If amenorrhea is not directly dependent on the blood state it is 
related to the condition of the nervous system. 

(d) Mental overwork in schoolgirls is sometimes responsible for 
the absence of the menstrual flow. Sudden grief, worry, or fear, 
or grave hysteria, melancholia, or some of the other psychoses, are 
often attended by amenorrhea. 

{e) Amenorrhea from retained menstruation due to atresia of tlie 
genital canal is comparatively rare. Necrosis of the vagina or 
cei-vix following prolonged and difficult labors, the wearing of 
neglected pessaries, or injury of the vagina from caustics, occasion- 
ally cause cicatricial stenosis to the extent that the secretions of 
the uterus are dammed up. In this event the absence of menstrua- 
tion will be attended by crampy pains and menstrual molimina. 

If a girl does not menstruate after she has passed her sixteenth 
year, the physician should inquire into the state of her general 
health, making whatever physical examination is necessary to 
arrive at a diagnosis of systemic disorder. The blood should be 
examined both as regards the number of red corpuscles and the 
percentage of hemoglobin. Failing to find any constitutional cause 
for the amenorrhea, a local examination should be made, and except 
in the rare cases of phlegmatic girls of good sense, with the aid of 
an anesthetic. 

Should the patient oxperienc^e menstrual molimina without a 
flow, local examination should l)e made without a previous inquiry 
into the constitutional state. 

Neglect to investigate has resulteMl in serious harm in the cases of 
retained menstruation from im{)(Tforate hymen or atresia, through 
dilatation of the uterus and tubers with rupture of the latter into 
the abdominal cavity. 

In women who hav(* been exposed to sexual intercourse, preg- 
nancy should always hi' in th(^ physician's mind as a probable cause 
of amenorrliea, and aft(T the foi-tieth ye^ar the possibility of the 
bc^gimiing of the menopause* should be considered. 

In every casi^ of amenorrhea the general physical condition of 
the patient should first engage the physician's attention, — ^the 
nervous system and the blood state being thoroughly investigated. 



LEtCORRHE.\ 



143 



LEUCORRHEA 

Lc*ucorrhea, or *' whiter" (from ^coxfJy, white, and fima^ flow), 
IS the gefirrio name commonly given to any discharge from the 
vulva, other than blcKnl. 

rriiler normal renditions the inner surface of the \iilva is simply 

Tnoif?t during the intermenstrual time, exeept just before and jut^t 

after menstniation, when the clisehartije may be enough to neceHsitate 

wearing a napkin* The normal moif^ture is made up of elements 

from four different sourees, in varying amounts, namely: secretion 

frora the uterine eavity jiroper, secretion from the rer\neal canal, 

epithelium from the vat^ina. and secretions from the vulva. The 

eecretiun from the uterine eavity is a clear^ trarLspari*nt fluid, small 

inamount, and ha\ing an alkaline reaction; that from the cervical 

I canal is tenacious, transpaniit, and thick like the white of an egg. 

[The epithelium cast off from the vagina is mixed with the uterine 

ret*cretions to form a milky fluid which is generally small in amount. 

The sweat and ^eliaceous glands of the lodva make a secretion 

of considerable amount. fi»rming smegma, which is found in the 

folds about the nymph;e ami under tlie prepuce. Besiiles this 

there is the glairy mucus secreted by the glands of Bartholin and 

Skene. 

Char.\cter of thk Discil%hoe in Lkucorrhea 



We will now consider the discharges undt^r almonna! conditions, 
taking up first the different cliaracters of tin* discharges and thru 
the probable meaning of the various dischargers occiuring in girls 
and women of different sfx-ial conditirms. 

White Discharge.— It is wliite, creamy or curdy, or visciil and 
dflftr. It stiffens the linen but does not st^in it. It may mean 
, jHvic congestion, endometritis, or laceration of the cervix, with or 
without uterine nmlpasition. 

Yellow Discharge. — It is light j^ellow (nuico-punilent), marketUy 
yellow (purulent) I or greenish yellow (gonococcus infection). It 
may mean purulent endometritis, a j>elvic absi-ess discharging 
tfu'ough the vagina, py*mietra ass<M'iated with cancer of the cervix, 
mudf most frequent of all, gonococcus infection of vaginai cervix, 
thra, or the vulval glands. 



144 THE CHIEF SYMPTOMS OF PELVIC DISEASE 

Watery Discharge. — ^This is a clear, colorless fluid that does not 
stiffen the linen. It may have color enough to stain the Uncn. 
It may mean uterine congestion, endometritis, intermittent hydro- 
salpinx, submucous fibroids, or cancer of the uterus, especially 
cancer of the body. Under watery discharge must be included 
leakage of urine from a urinary fistula or incontinence. Here the 
odor of urine is apparent. 

Fetid Discharge. — Foul-smelling discharge may be purulent or 
watery in character arid results from necrosis of tissues. It may 
be caused by a neglected, retained pessary, by a sloughing sub- 
mucous fibroid or polyp, by decomposed products of conception, 
and, most frecjuent of all, by cancer of the uterus, especially cancer 
of the cervix; the discharge in the last case having a characteristic 
odor. 

Bloody Discharge. — ^A discharge tinged with blood, occurring dur- 
ing the intermenstrual period, stains and stiffens the linen. It 
may be due to endometritis, laceration of the cervix, submucous 
fibroid, polyp, vaginitis, or cancer. A scanty hrownuh discJianje 
lasting for several weeks may indicate a disintegrating uterine decidna 
in the case of ruptured tubal pregnancy (see Chapter XIX., page 353), 
or it may mean the slow breaking up of a blood clot within the 
uterine cavity. 

OCCURREXCE OF LeUCORRHEA 

Leucorrhea in Children^ — ^The immediate cause of leucorrhea in 
children is vulvitis. A white discharge occurs sometimes in poorly 
nourished children, and int(\stinal worms, dirt, and struma have 
Ixvn assigned as causes. Just how th(?se are factors, and why some 
chihh'en affected by them have leucorrhea and others do not, has 
not b(^en explaint^l. One author has assigned the staphylococcus 
as a cause and others hav(» found a large variety of bacteria in these 
cas(\s. Masturbation is undoubtcHlly a cause of vulvitis and there- 
fore of leucorrhea with a white discharge^ never of leucorrhea with 
a purulent discharge. The practic(^ is by no means infrequent 
among neurotic children. (S(m^ Chapter XXVIIL, page 574.) Pu- 
rulent vulvitis is (lu(^ to gonococcus infection in a majority of cases. 
R(Tent bacteriological investigations of (epidemics of this disease 
in institutions, public baths, and elsewhere prove that thegonococcus 



LEUrOHRIlKA 



U5 



IB present in nearly all nf ihr i-u-si's and tliat the clLse^ist^ is most 
[frcMjuent in clulrlren imiler five years of age. There occurs rarely in 
^little girls a vulvovaginitis with purulent tlise}iarg<% perhaps tluo 
jto the staphyloeoecas. Vaginitis is generally asvsociated with 
v\il\itis, and ga!pingiti*s ilevelops in a eertain proportion of the 
leases. The disea.^ leavers disabling traces not only in closure of 
the tubes but also tn the form of adhesions of the nyniphte to the 
'prepuce and to each other. (See Chapter XXL, page 394,) 

Leucorrhea in Virgins.— Transitory leucorrhea in a virgin may be 

. due to a [X'lvic congestion. The discliarge under these conditions is 

I generally either white ami curdy, or clear antl viseiil. or a mixture 

of the two. Sometimes the leucorrhea if of the vistdd tyjx? is from 

the .secretion of the glands of Bartholin causeil by sexual ft^elings. 

In only exceptional instances can a male physician ascertain the 

faetii bi this respect, so tliat if such a state of affftirs is susjicctefl 

the patient should be referred to a woman j>hysician. Persistent 

leucorrhea in a vii-gin is due to pelvic congestion or c*ndometritis 

in the young, or, in the old, may be due to cancer of the body of 

the uterus or to a submucous filiroiil. llenorrhagia is generally 

an attending symptom. A local examination should be made 

, because in this way oidy can an intelligent opinion be formed of 

' the condition of tht* uterine organs. After the examination has 

been made the state of the general health should nnieive ciireful 

^attention in the way of corivctiiig anemia, whether or not local 

treat nient is employed in con junction wnth it. 

Leucorrhea in Married Women, — In women who are accustomal 
to sexual intereoujif*e a white discharge may mean simple pelvic 
.congestion. Tliis is not an imusual condition in the recently mar- 
ried, the congestion of tlve pehdc organs Ixing excessive bc^eause 
of intemperance in coitus. So also, a leucorrhea may result from 
habitual incomplete coitus, part of the discharge coming from the 
Uterine cavity antl part ivom Bartholin's glands. '* Whites** aiv a 
fffj'mptom of laceration of the cervix, (Tosions, endouietritis, and 
uterine misplacements. A yellow discharge is found hi tin* \tm- 
fOus sorts of vaginitis (st^e Chapter XX., page 361), Wiginitis 
following infection rluring or after confinement is very common, 
anfl also gonorrheal vaginitis. The gonorrheal sort is apt to date 
from marriage or intercourse and to bi* aecompanied by frequent 
and smarting micturition, A vulvo-vaginal abscess or a bubo may 
m 



146 THE CHIEF SYMPTOMS OF PELVIC DISEASE 

have complicated the disease. Parous women are more apt to 
have cancer of the cemx than nuUipane. This disease is attended 
by a yellow or blooily vaginal discharge. Retained products of 
conception cause a bloody discharge, as a rule, and sloughmg 
fibroids or polj-pi a foul, purulent discharge, while a submucous 
fibroid causes a thin, water}' leucorrhea. A persisting brownish 
discharge may mean extra-uterine pregnancy. 

Leucorrhea in Old Women. — ^AVomen who have passed the meno- 
pause should have no vaginal discharge if their uterine organs have 
atrophied in a normal manner. If there is a white discharge it 
may be due to senile endometritis, caused by old-standmg uterine 
lesions. A yellow or bloody discharge means either senile vaginitis 
or cancer, and so often the latter that no time should be lost in 
investigating the condition of the uterine organs as soon as the 
symptom is reported. 

DYSPAREUNIA 

Dj'spareunia, from the Greek o'j^r:df,-u>o^^ ill-mated, is the 
name given to pain or difficulty in sexual intercours<\ 

Difficulty in accomplishing the sexual act may be due to (1) 
psychoneurological, or to (2) anatomical causes. Of (1) the 
psychoneurological causes, we may enimierate repulsion or aversion 
on the i)art of the wife. Cases are on reconi where women have 
refused to let their husl^ands touch thorn throughout a long series 
of years of married life b(vause of n^pulsion, or the husbapd^s 
awkwanl manner of approach, .\nother of the psychoneurological 
causes is vaginisnnis (see Cliapter XX., page 378), a spasmodic 
reflex contraction of the levator ani and other muscles about the 
\'ulva excit(Hl by the slightest touch. This afifection may be 
associated with actual smallness of the vagina or an irritable h)Tnen, 
or it may Ixi due entirely to an irritable condition of the nervous 
system. 

(2) Anatomical causes of both difficult and painful intercourse 
are (a) thos(^ situated in the vulva or lower vagina — a rigid hymen, 
a small vagina, either from faulty gro^vih or from cicatricial stenosis, 
clironie vaginitis, urethral caruncle, vulvitis, a ^^Ivo-vaginal 
al^scess, chancres or chancroids of the vulva, and kraurosis vulva*; 
and (6) deeper-seated comlitions, of which the chief are, — ^metritis. 



STERILITV 



147 



lacerations of the cervix with tender cicatrieoi?, prolapsed and 

■ tender ovaries, and masses of pelvic inflanmiaton* exudate. It is 
unnecessary to consider ht-re the acute inflammations of \nilva, 
vagina, ute^u^^, ovaries and tulx^s, or pehic peritont*um because, 
of necessity, intercoui'se (*ott]d not take place in the presence of 
BUch conditions. 

Disproijnrtion Iji-twc^'n thf* size of the penis and the caliber of 
the vagina, or a tlcticit*ncy In the luljricating fluids secrcteil by the 
proetate in the male and Bartholin's glanrls in the female, may be 
causes of d>^pareunia. 

In getting a history of imin during; intercourse the physician must 
inquire whether the pain is at the lx*ginniiig, or after the penis has 

■ entered the vagina. If at the beginning, the cause is probably to 
be souglit in vnginisimis or in class (a) of the anatomical causes; if 
after the penetration uf tlie male organ the cause is in class (i). 
Inquiry should be matle whether the pain has Ix^en present with 
coitus since the Ix^ginning of married Ufe, or has been noted follow- 
ing the occurrence of an\* of the sy mi>t<ims of jxrKdc disease. 

Physical examination will reveal all of tlie anatomical causes and 
vaginismus. 

STERILITY 



I 



Sterility, from the Latin word sterilis, barren, meaning, when 
jqipHiHi to a woman, that she has not Ix-irne a living child, — not that 
•he is unable to, — is classified as ahmlute (primary) f<ieriliiy wherf* 
no child has lHX?n bonie and no miscarriage, or no abortion has 
taken pla<!c, as relatii^e (secondary) sterility where one or more preg- 
nan«*i<'s have occurml, followed by a j.»eri(xi of un fruit fulness, or foe- 
utUiliveHieriJity, infeiiility caustMl by the prevention of conception. 

Sterility may be due either to the husband or to the wife, possibly 
to lx»th, therefore no physician should submit a woman to local 
trt^atnient for sterility without first assuring himself that the 
husband*!* organs of proc*rt*ation are functionating normally. This 
is done by questioning, by an examination of the penis and testicles, 
and by a microscopical examination of semen spent into a glass 
vial, wliich is then eorke<l and kept warm at the lx>dy tempeniture, 
hy placing it in warm water. Questioning, not in the presence of 
the wife, will determine whether the man thinks that coitus is 




148 THE CHIEF SYMPTOMS OF PELVIC DISEASE 

performcMl normally, or whether he has noticed any abnormality of 
his generative organs, or has had gonorrhea. Examination of the 
penis an<l testicles by the physician may detect some anomaly that 
the patient had not susp(»cted: — it may show a gleety mx^thral 
discharge. Microscopical examination of the semen on a warm 
slide will show whether it contains living spermatozoa or not. 
Care must be exercised not to heat the l)ottle containing the s(mi(?n 
too much or to let it get cold, or the si)ermatozoa may be killed. 

Sterility in the Male 

The frequency with which the fault li(»s with the husband in 
cases of sterility is obviously a matter difficult to determine. San- 
ger, and Lier and Ascher (quotcnl l)v K(»lly, ''Medical Gynecology'') 
have studied this matter in a number of cases. Of 242 husbands of 
sterile marriages (^xaminexl by these authoi-s, 104, or 43 per cent, 
showed absence of living spermatozoa, or deficiency of semen and 
imi)otency, the proportions being, resi)ectively, 79 cases, and 25 
cases. Further, 55 of the men had infected their wives with 
gonorrhea, pro< luring, as the authors assume, indirect sterility. 

A fair infcTence from tlu\<i* statistics, by three competent observ- 
ers^ is that in sonu^thing over half of the sterile marriages the fault 
lies with the husband, hence the importance of investigating the 
man as well as the woman. 

Steuility i\ Women 

Age as a Factor. — As pointed out by Matthews Duncan and shown 
in the following table, the age at marriage is the chief factor in the 
expectation of sterility. 



Arc at Marriage. 


15-PJ 

4:5.7 


2(>-24 


2r>-29 


30-34 


35-39 


40-44 


45-49 


Perc<'iitagc of wives bearing a 
child within two years .... 


90.5 


75.8 


62.9 


40.9 


15.4 


..3 



From this it will I>e seen that fecundity is greatest in women 
who have Ix'cn married Ix't ween the ages of twenty and twenty-four, 
and decreas(\< progressively until the menopause. 



STERILITY 



149 



I 



Duiieuii hsfi shown also l»y his statiHtirs that of the wives marritHl 
l>ptwe«*ii the ages of twenty and twenty-four who wvrv all ft^rti!**, 
ojily fsix hikI two-t«^iiths [)(*r tTnt In'^aii to Ix'ar aftrr thn^e yi^ai-^ 
of niarriHgc\ In other words, wht^n the ('X|>cctation of fertility is 
grt'ate^st the question of i>rol>ahlr sterility is soonest <lf*fiiled. 

The age of the wife has a lx»aring on sterility, for, atTording to 
this same author's statisties, the following percentages were 
ob^rvtHl:^ — 



AfleofWiVfa»t 


1&-19 


20-24 


25-20 


30-34 


3A-39 


40-44 


46-49 


SOmuI 
ow. 


Totml. 


Number of wive* 

ob^rved 

Sterile wives... J 
Percentage sterile 


700 
51 
7.3 


J. 835 




1,120 
311 
27.7 


402 

151 

37.5 


206 

109 
53.2 


no 

100 
90.9 


46 

44 
95.6 


29 

29 
100 


4,447 
725 
16.3 



Other Factors.^Tlie factors essential for proereation» as far as the 
woman is concemetl, are, the presence of a living o\Tam, a healthy 
endoinetrium upon which the o\^nn may develop, i>ennealjiljty of 
the genital tract so that tlie spermatozoon may reach the ovum, 
anci wcretlons of the genital tract that ai*e not inimical to the life 
of the. spermatozoon, or that do not bar its upward progress to the 
ovum. 

Entninee of the penis into the vagina is not necessary to produce 
eonce[>tion, for cases are on record Avhere pregtiancy has occuritHl, 
and women have come to la(^M>r even, with an unruptured hymen 
which prei^nte«l oidy a nimute oiiening; therefore deposition of 
semen on the \'ulva is all that is ntM'essary in some cases. Also, 
sexual feeling is not a nect-ssity, ffir women have eonceivnj 
nfter intercourse while unconscious from intoxication and othcT 
eausc^^ and artificial insemination has proiluced conception. Still, 
conception \s rnort* likely to occur if the penis enters the vagina and 
if sexual ftx'lings with an orga^sm are present, the spermatozoa, in 
all proliability, fintUng a more ready entrance to the uterine cavity 
fluring the orgasm. 

I-ea\ing out of accoiuit the ^luestion of age. already considered, 
the following may h^ enumerated as rauses of sterility in wotnen: — 
(1) Ban* to conception in the form f>f atromalit:^ and diseases of the 
uterine organs. (2) Conditions of the uterine organs caui?ing 
interruption of pregnancy and death of the fertilize*! ovum or fetus 




150 THE CHIEF SYMPTOMS OF PELVIC DISEASE 

(abortion and cxtra-iiterinc prcgnancy), an(i (3) CJonstitutional 
diseases and general causes acting either in preventing conception, 
or in terminating it after it has begun. 

1. Anomalies and Diseases of the Uterine Organs. — ^The following 
is a list of the pelvic diseases commonly found associated with 
sterility, beginning with the vulva and ending with the ovaries: — 

Imperforate or rigid hymen (preventing penetration). 

Tumors of the vulva (preventing penetration). 

Urethral caruncle (dyspareunia). 

Absence or atresia of the vagina (preventing penetration). 

Vaginismus (preventing penetration). 

Vaginitis (destruction of spermatozoa by discharges, especially 
gonorrhea). 

Rupture of the pelvic floor (allowing semen to run out). 

Inversion of the vagina with uterine prolapse (preventing in- 
semination). 

Infantile uterus (lack of normal endometrium). 

Anteflexion of the uterus (mechanical obstruction, together with 
endometrial discharges). 

Endometritis and polypi (abnormal endometrium and discharge). 

Erosions of the cervix (spermatozoa barred, or killed by dis- 
charge). 

Lacerations of the cervix (spennatozoa barred, or killed by 
discharge). 

Cancer of the cervix and body (spermatozoa barred, or killed 
by discharge). 

Fibroids of the uterus (unknowTi direct cause). 

Hyperin volution of the uterus (abnormal endometrium). 

Nodular and obliterating salpingitis (very frequent cause, 
especially of one-child sterility. Canal of tube obstructed by 
nodules or closed by adhesive inflanmiation). 

Under-development or atrophy of the ovaries (oophoron of 
ovary afi'ected, so that healthy ova are not produced, or are not 
thrown off). 

Ovarian tumoi*s (all of functionating oophoron destroyed, or 
ova can not reach tubal ostium). 

Adhesions about the ovaries (same as ovarian tumors). 

2. Conditions of the Uteri7i€ Oryans that Cause Interruption of 
Pregnancy. — ^The chief local causes of abortion are: — 



Pelvic congestion from excessive roitus. 

Endometritis (abiionual endoinetriuin). 

Retrodisplacements of the uterus (preventing tlir progressive 
enJargcrnent of the uterus)* 

Uircmiions of the cervix (through endometritis and lack of 
protection of the ovum or fetus). 

Syphilis of the pluet'ota or decidua. 

Introduction of foreign borlies, sueh as catheters, into the uterus. 

Follicular salpingitis (funnshhig diverticula for the ilevelopment 
of extra-uterine gestation). 

3. Const Uutioriai Diseases and General Causes.— The chief con- 
stitutional affections that either cause failure to conceive, or in- 
terrupt pregnancy are: — 

The acute diseast^s, especially the infectious diseaaes, such as 
acute rheuniatisni^ scarlatina^ and typhoid fever. 

Alcoholism and morphinism. 

Sypliilis (frequent cause. From sy(>hiHs of plac-enta and 
deciilua, or transmittiHl from father tlirou^h s^pmeu). 

ExccHsjve ob^ity^ occur ring rapit Uy. 

Anemia, associatecl with chronic heart disease, kidney disease, 
dial)etc*s, or tulxTculosis, 

The psychosi^s (mental (:hs<?ases or sudtlen nervous shocks). 

Inbreeiling fmamage of cousins). 

Masturlmtion (chronic pelvic congestion from conjugal onan- 
isaif simple masturbation, or douches). • 

VESICAL SYMPTOMS 



The chief symptoms of disease or derangement of function of the 
urinary organs are: — 

(1) Difficult, retarded, or painful urination, dymria, 

(2) To«) frequent urination, /re^we^ii miciuriimi, 

(3) Incontinence of urine, enuresis, 

(4) Retention of urine, ischuria. 

(5) Suppression of urine, anuria. 
I, Dysuria, from the Greek words, ^'Ji% ill, and oupu,^ urine, 

ies an inulnlity to start the stream and to empty the i)ladder, 
Jso pain attending the act of mictiu-ition. When the urine 
ttptised drop by drop with spasmodic pain the condition is known 



152 THE CHIEF SYMPTOMS OF PELVIC DISEASE 

as strangury (from (frpdy^^ a drop and ohpov^ urine). It is found 
in cystitis, especially in those forms of cystitis that are due to 
poisoning by cantharides or turpentine. 

Painful or difficult urination is a very common symptom com- 
plained of by women who suffer with gynecological affections. 
Some authors estimate the number of such women who have vesical 
symptoms as high as one-half of all the cases applying to the 
physician for relief. A greater or less degree of dysuria ahnost 
invariably accompanies pelvic inflammation and also gonococcus 
infection, but more of this later. 

The physician will do well to rule out first the general constitu- 
tional causes of dysuria. Pain and burning during urination may 
be due to a too acid or too concentrated urine. This is the case in 
patients who habitually ingest a small quantity of fluids and also 
in lithemic women. Sometimes this symptom is indicative of 
acute nephritis, because then the urine is concentrated. The 
ingestion or absorption, through the lungs or skin, of turpentine 
may cause dysuria, and in the same manner cantharides, mustard, 
and pepper, when taken internally or applied to the skin, may be 
attended by this bladder symptom. 

The local causes of dysuria, beginning at the meatus urinarius, 
are, urethral caruncle (see Chapter XXIII., page 453). Here the 
pain may be so severe that the nervous system is upset and the 
patient becomes melancholic. The pain is described as ''scalding," 
''stabbing,'' "shooting,'' or "cutting," and is felt while the urine 
is passing over the caruncle and for some little time afterward. 
The pain is a[)t to be aggravated during the menstrual period, and 
the dread of the pain is often so great that urination is deferred as 
long as possible, so that retention may result. In many of these 
cases there is a constant pain in the vulva as well as the pain which 
attends micturition, the constant i)ain being aggravated by walking. 

Dyspareunia generally accompanies dysuria in these cases, and 
there may be bleeding on coitus. 

Urethritis is due in a great majority of cases to gonorrhea and is 
a common cause of dysuria. Anything that increases the con- 
gestion of the pelvic organs, such as menstruation or pregnancy, 
(exaggerates the inflammation of the urethra, and therefore increases 
the severity of the symptom of difficult or painful micturition. 
(See Chapter XXIII., page 450.) 



VESICAL S^IPTOMS 



153 



Dovmivard disl4}caii<m of the urethra is a not infrequent cause of 
lUflieulty in i>a.ssin|: urine, ami so y stricture of the urethra, one of 
the mnult!? of un'tluitts. Suburethnd uhsvess ^viwraWy cau-ses 
clilficulty in urinatioTu It i.s a subacute diseaMe ami is attenLled by 
j)ain» fever^ ilyspareimia, and the intermittent ilischarges of pus. 

The eausi^ of dysuria that are situated in the hiaililer are: — 

(a) Caladi and foreign bodies, whieh are ui^ually attended by 
e>n^ttis; {h) cybtitis in its various fonns (see Clmpter XXI\\^ i>age 
462); and the (c) new gronih^ of the bladder , the most frequent of 
which are papilloma and cancer, 

a. Too Frequent Urination* — The time-worn term '^irritable 
bladder" lias ^ivcn way to a more rational ant I more exaet descri}> 
tion of both the sjiriptoms and the pathological eoriditions present. 
To esiabli.^h the fact of tw> fre(|uent urination, tlie phyj^ician nuist 
inquire a^s to the patient's habit as regards emptying the bladder. 
Many women are accustomed to void urine only at long intervals 

tinie, pt^rliajjs once or twice a day. Perhaps tliey ingest very 
ill quantities of fluids. Under the influence of excitement ^ of 
Jaking more Huitls, or of cold, the amount of urine may Ik* larger, 
ad the desire to pass it consequently more pressing and more 
rn*quent. On the other liand, a small amoimt of fluid taken by 
the mouth and aliundant jiei^piration will liiminisli the amount 
of urine secreted, and ther€4ore the necessity for passing it. 

Inquiry into too frerjuent urination should deal with the custom 
of the individual undtT ordinary conditions of health. How many 
times t)y day, anti how many tiriii:s by night. Tuo frequent urina^ 
tion must be differentiated from ineontuience, and this will be 
tnken up in the s4H:tion nn iurtiidinence. 

Mcjst comlitions which make nueturition painfid also cause it 
to Ix^ too freciuent. Tliis is the case with the inflammations of the 
pelvic organs. Here we are considering only the affections which 
are cliirfly <listinguished by abnormal frequency. 

Ihirimj pretjmmeij \\\v urethra and the ne<*k of the bladder partake 
€>f the congi^stion of all the ix*lvic organs at this time. Why this 
congestion of the neck of the bladder is attends I by too fi*e(|uent 
miclurition in some pregnant women and not in others we do not 
know, 

Tlie statemc*nt may Ix^ made ihat, as a general rule, micturition 

more frecjuent during [tregnancy, espt^cially during early preg- 



154 THE CHIEF SYMPTOMS OF PELVIC DISEASE 

nancy, than at oIIkt times. AVomen who suffer with uterine 
disease may have too frecjuent micturition only at the time of 
menstruation because of the additional congestion of the neck of 
the bladder at that i)erio(l. 

The ingestion of large quantities of fluids, especially of those 
which have a diuretic effect, like tea, coffee, and beer, is followed 
by frequent micturition, so also are diabetes mellitus, diabetes 
insipidus, and hysteria, Ix^cause of the secretion of an abundant 
supply of urine in these disc^ases. 

Urethritis aiid stricture of the urethra are causes of frequency, — 
even congenital smallness of the meatus may cause frequency. 
Contracted bladder, by not permitting any considerable quantity of 
urine to accumulate, causes frequency, and so do tumors of the 
bladder situated in the neighborhood of the vesical trigone. 

Cystitis is attended by increased frequency of micturition, in 
fact it is a cardinal symptom, but there are no data in hand to 
show that increased frcijuency is due to ureteral or kidney disease 
where the bladder is not at the same time affected, although put 
from a suppurating kidney, in the same manner as concentrated 
urine, — perhaps containing cr}''stals, — may stimulate the bladder 
neck and cause freciuency of urination, also the passage of a renal 
calculus along the ureter may cause a reflex desire to urinate. The 
bladder is so frequently involved in cases of pyelitis and ureteral 
calculus, however, that frequency of urination may be considered 
a symi)toni of those diseases. 

3. Incontinence of Urine (Enuresis), — 1. Ia)co1 Causes. — Inability 
to control the escape^ of urine from the bladder, or the passing of 
it unconsciously, may be due first of all to an overdistended bladder. 
In this event the urine escapes a little at a time and the patient 
may not realize that the bladder is overfilled; her complaint being 
only that her clothes are wet or that she can not control the urine, 
permanent incontinence exists in v(*sic()-vaginal fistula, also in 
vesico-utorine and uretero- vaginal, or uretero-uterine fistula. (See 
Chapter XXIV., page 474.) 

Incontinence is a feature in epispadias, downward dislocation 
of the urethra, and in some cases of prolai)S(^ of the uterus, and in 
cystoccile. In the latter cases the urine may escape only when the 
intra-abdominal pressure is increascnl in laughing, coughmg, sneez- 
ing, or straining. 



I 



VESICAL SYMPTOMS 



155 



I 




2. (ieneral Causes,— Nociurnal enurefffs is a form of uicontineticr 
found in tvliildrerh llviv large t|uantitit'8 of urint* are voided, quite 
uncon8ciou.sly, at night only, the aflfeetion being supposefl to be 
caused by an over reflex excitability of the nervous mechanisn^i of 
the bladder. Rarely a local abnoriiuility, such as aji a^Uaereiit 
prepuce, may act as a cause. 

Incontinence may be due to a dlsonhT of th*- lirain itself (a), or 
(b) to some affection of that j lortion of the spinal cord which puts 
the brain mto communication with the vesical centers in the sacral 
flegments of the cord. 

(a) Tlie conditions whieli inhibit conscious cerebral acti%ity aret 
coma, from whatever eause^ as alcohol, ejjilepvsy, or cerebral hem- 
orrhage; some insanities; sunstroke; shock, and the poisons of 
some of the infectious diseasc\s, as diphtheria and typhoid fever. 

(/») The lesions w^hich interfere with the conduction bt^tween the 
lirain and the vesical centres in the lower cord are: myelitis, 
injuries and tumors of the cord, spinal meningitis, and locomotor 
ataxia. 

If the reflexes are entirely alx)lished total paralysis of the bladder 
with retention and dribbling of urine ensues; if the paralysis is 
partial, there will be partial retention, with occasional voiding of 
urine and it^ involuntaiy escape after voluntary urination is 
finished* The last happening is a frefjuent occmTcnce in locomotor 
ataxia* 

4. Retention of Urine (Ischima). — The urine may he retained in 
the bladder and the patient unable to void it in the same diseases 
of the brain and spinal cord as in the case of incontinence just 
noteil. It is a pretty constant symptom of multiple sclerosis. 
Retention often alternates with incontini»nce in cases of coma 
and the typhoid state. Iletention is conunoo m hysteria^ and in 
order that ovcrdistention of the bladdc-r may be avoidetl, tlif^ 
physician should palpate and p«'rcuss the ]ow*i- alidomen of the 
hysterical woman to detect a full bladder. Retention is not un- 
common during late prexpiancy, and. whatever the cause, may result 
in a lack of expelling power and atony of the bladder. Retention 

to bt* expected in inmrcemikm of the reirofJexed pregnant utenis^ 

d may occur, rather infrecjuently, in fibroids and o\'arian tumors. 
Retention 1ms occurred bc*cause of blocking of the urethra by a 
suburt*thral abscess, or by cancer of the lu'ethra. Temporary re- 




156 THE CHIEF SYMPTOMS OF PELVIC DISEASE 

tention has been caused by the occluding of the urethra by a cal- 
culus or a i)edunculateil tumor of the bladder, and lodgment of a 
stone in the ureter may produce n»tention by causing spasm of the 
s{)hincter vesicae. 

5. Suppressi<Hi of Ac Urine (Anuria). — If urine is not secreted, or 
if secreted does not reach the bladder, the condition is known as 
suppression of urine, or anuria. The catheter must be passed and 
the bladder found empty before anuria may be said to be present. 

Anuria, a rare condition, may occur in hysteria, in uremia, during 
the terminal stage of chronic nephritis, in acute nephritis, or in 
poisoning by turpentine, lead, phosphorus, or cantharides. Sup- 
pression of urine has been noted in yellow fever, typhoid fever, and 
the late stages of acute yellow atrophy of the liver, and in sunstroke. 

In hysterical anuria the diagnosis is established by passing the 
catheter and then repeating the procedure after a definite interval 
of time, — say two hours, when the patient does not expect it, — 
thus obviating conscious or unconscious malingering. If both 
ureters are obstructed by disease within, or by pressure from with- 
out (see Chapter XXV., page 489), so that no urine reaches the 
bladder, the condition is kno\\Ti as obstructive anuria. This is a 
rare condition, the diagnosis being made by cystoscopy and ure- 
teral catheterization. 

RECTAL SYMPTOMS 

In taking the history, certain facts pointing toward rectal disease 
are to be noted; among them are the occurrence of slight morning 
diarrhea, continuing over a long period of time and alternating with 
attacks of constipation, a sense of weight in the pelvis, dull pain 
in the region of the sacrum, and pain or swelling of the left lower 
limb. 

Pain. — As to pain, ask when it was first noticed, the exact situa- 
tion, how long the attack usually lasts, what effect has defecation 
upon it, and how severe it is. The most probable cause of pain 
occurring over a long period of time is fiasure. When of recent 
occurr(»nce, i)ain may be (hie to fissure, complete fistula, blind 
internal fistula, or i)rolaps(Ml internal piles. If the pain is in the 
anus the chances are that tlie l(\^i()n is there, whereas if it is in the 
region of the sacrum the lesipn is ])rol)ably in the rectum proper. 



FECAL SYMPTOMS 



I 



If the pain last^ after ^lefccation for several hour?, the [irolmhio 
diagnosis i^ fissuj^e or blind internal fi:?tula, or L-oniplete ftstnla w itli 

largo internal ofx^niiig. Pain t'eaj^rs after defecation in the* ease 
bf .stricture, but bi the ca.se of piles the pain iK*rsi»ts a.s long as the 
piles are outside the sphincter. 

Pain folJowing'defeeation indicates fissure, blintl internal fistula^ 
proIa|>S(*d internal piles, or a |>rotryc|pd polypus or tunior. Pain 
aeeonipanying constJi>ation and nOieved only l>y ein))tying the 
rectum^ is jjrobablydue to inipaetion of feces, ulceration* or stricture. 
Pain or itching, coming only after the jiatient has gone to be<l, may 
mean external piles or eczema about the anus. 

Hemorrhage. — Hemorrhage from the rectum is either (a) associ- 
atoti with defecation, or (b) it is indept^ndent of defecation. 

(a) Bleeding internal piles and fissure cause loss of Wood with 
the stCKils. When the feee^s passed are only smearrd with a little 
blood, the diagnosis may be ulcer of the rectunK Profuse hernor- 
rhage sfmietinics accomparues diiecation in the eajsiMif internal jiiles, 
a slight hemorrhage Ix^ing more usual in cases of prolapse, polyp, f>r 
\illous tumor. 

(b) Hemorrhage inde(x*ndent of defecation occurs in some caf*f»s 
of internal pil<^s, cancer, and, in the case of prolapsjMl growths, in 
prolapse of the nmcous membrane, in internal jnles. and in polyp. 
Continuous hemorrhage seldom lasts more than twenty-four hours 

F^and, as a rule, hemorrhage in rectal disease is intermittent. Blood 
may come from the skin around the anus in the ease of eczema, 
fissurcni, external piles, or tulierculosi.s in that region. 

Rectal Discharge, — Besides blooil, there may be discharged from 
the rectum, mucus, nuicopus, anrl serous fluid. An increase in 
the amount of the rectal nmcus is found in proctitis, in internal 
piles, in prolajise, and in stricture with invagination of the rectum. 

In the case of elir<:)nic hypertro|ihic [proctitis the amoimt of 
mucus passed jmt anuni, often involuntarily, is so gn^at that the 
[tutient is forccnl to wear a najikin. Pus is due to an uljsc(»ss which 
ha» ruptiUTfl into the bowel, or to a fistula-in-ano, Muco-pus is 
generally found in ulceration, whether malignant or simple. 

Serous fluifl is passim! in cases of villcKis tumor, often in large 
rjnantitic^ and involuntarily. Besides making inquiry on these 
painti« the patient's linen should Imt- uisjM>cteib 

Fecal AccumuJatian,— The rectum is almost always found fillec! 



158 THE CHIEF SYMPTOMS OF PELVIC DISEASE 

with feces in cases of fissure, internal piles, eczema of the anus, and 
hjTXjrtrophy of the external sphincter from whatever cause. In 
the case of stricture of the rectum the accumulation of feces will be 
found above the stricture, not below. The symptoms of this 
condition may lx» nothing more than a sense of fulness in the rectum, 
or there may be no sjTnptoms. Digital examination makes the 
diagnosis. The physician should have the probabilities in mind 
before making the examination. 

Difficulty in Defecation. — ^\Vith this condition there is present a 
more or less constant desire to empty the bowel, and defecation is 
not attended by relief. It is not the same as constipation. If the 
dread of going to stool is due to pain caused by the act, the probable 
diagnosis is fissure, or ulcer, or a partly torn off polj^), causing 
spasm of the sphincter. If there is a tightness of the sphincter, 
the muscle will be found hypertrophied and non-dilatable. If there 
is much pain with straining bc^fore and during defecation and 
disappearing entirely aftcT defecation, leaving a sense of only 
partial reli(*f , a stricture is probably present. 

Character of the Feces. — Diarrhea is not a true diarrhea unless it 
consists of a frequent discharge of fecal matter, whether solid, semi- 
solid, or fluid. True diarrh(»a is not frequently met with in rectal 
disease. If the feces are passed in short pieces of small caliber, with 
a little mucus and blood, or pus and blood, a stricture is probably 
present. If there is much blood and the feces are not in small 
pieces, cancer is to be suspected. In prolapse or invagination of 
the rectum, the fec(*s are apt to be scybalous. 

Protrusion from the Anus. — This occurs in internal piles, polyp, 
and pedunculatiHl tumors, including villous tumors and cancer. If 
the protrusion is associated with defecation, the tumor returning to 
the n^ctum spontaneously soon after, — the probable diagnosis is 
internal piles, a polyp with short pedicle, a moderate degree of 
prolapse, or a villous tumor. Wh(»n the protrusion remains down for 
several houi-s, the probable diagnosis is internal piles which have 
become pe(lunculat(»d, a polyp with long pedicle, a marked degree of 
prolapse, or a villous tumor, and also, if protrusion occurs on stand- 
ing or straining, it is probably duo to an extreme degree of any of 
these. The afl'ections referred to in the preceding section will be 
fomid described at length in Chapter XXVI., pages 498, and 
523-525. 



OOCX^VGODYNIA 



159 



COCCYGODYNIA 



I 
I 



The tc*nn coceyi50<lyuia (from zoxx'j^^ coccyx, and «>'^>vr^, pain) 
is the name given by Sir James Y. Simpson to pain in the Region of 
the coecyx, an affection (XTurring almost entirely in women and 
jjc^nerally chie to injiu'v of the coccyx during lalxjr. Some time 
^rev'ioiii* to May, 1844, Di\ J. C, Nott, of Mobile, Alalmma, removed 
the last two coccygeal lx>nes in a young unmarried woman for 
'^neuralgia of the co<Tyx/' dut^ to caries of the coccyx^ following 
injurj^ from a falJ. This is the first recorded instance of co(*cy- 
godjiiia, which is very commonly associated with g>Tiecological 
affections. 

Coccygc^hnia may occur in men when due to iujmy, but it is 
extrrnuly rare. As in Xott s ca.-^^, the disease in woman may be 
aseociated with caries of the bone; this is, however, rare, and the 
pathological apI^earanc(^s of the specimens removed by operation 
show mast often disi^asr* of tlie joint bf^tween tiie first anil s<.*cond 
coccygeal bones. The thive lowTr bones aix? genemlly ankyloses 
in adults so that forcing them backwanl, — as in labor, — or forward, 
ns in a fall on the buttocks when the tbiglis are fl(^xcNl^ places the 
strain on the ordy movable joint, tliat Ix^tween the first and secontl 
piecf«. Besides injuiy ro the joints the coccyx may be^ fractmtHl, 
The etiology of the pain is obscure and some authors attribute it to 
rheumatism of the muscles in the neigliborhood of the coccyx, 
others to sprains of the ligaments, and still others to some affection 
of Lushka's coccygeal gland, wliich has a rich nerve supply. 

The i?\*mptoms consist of continuous pain in the region of the 
coeejic aggniVHtCH^l by sitting down and by rising from a sitting 
postun?. A hard seat causes especially severe pain and pain is 
exaggerated by defi»cation and by coitus. Mild cases are fairly 
common, but severe* ones are infrecpient. In the bad eases thei*e 
may b*.' constant pain along the eiilire hnigtii of the spinal colunm; 
the patient may get up from a sitting pasture by placiing the palm 

one hand uix>n the seat of the chair and the other on any con- 
^letiient support, and pashing the IknIv up by the anns as much tis 
possible^ so as to avoid t-nntracting the muscles of the pehic floor 
and the glutei. The bad casoe are usually the victims of 
netiraflthema. 




160 THE CHIEF SYMPTOMS OF PELVIC DISEASE 

In making the diagnosis, tenderness of the eoecyx to light pres- 
sure, both froni the skin surface and by a finger in the rectuni, is the 
chief feature. If there is dislocation the lower bones of the coccyx, 
grasped between the finger in the rectum and the thumb in the 
crease of the nates, may be thrown out of line with the upper bone, 
or bones. A fracture may be felt as a ridge on the surface of the 
coccyx. 

Tenderness over the cocc)rx by both vaginal and rectal digital 
examination may be found in proctitis (see Chapter XXVI., page 
5()6), therefore in establisliing the diagnosis of coccygodynia this 
disease must be ruled out. 



PRURITUS VULV^ 

Pruritus vulvae, or itching of the \iilva, is a S3rmptom which 
may be the source of a great deal of misery to its victim, and may 
lead to serious derangement of the health from loss of sleep and 
constant nervous irritation. In the severe grades it is often accom- 
panicKl b^ evidences of impairment of the nerv^ous system, such as 
frec^uency of micturition, indigestion, irritability of temper, and 
instability of disposition. It is a symptom and is undoubtedly 
due to a certain sort of irritation of the terminal filaments of the 
nerves in the skin of the vulva, but the pathology is, as yet, unknown. 
The causes of pruritus may be divided into: (1) irritating dis- 
charges from the vagina or bladder, (2) diseases of the vulva, and 
(3) neuroses. 

I. Irritating discharges from the vagina are, (a) leucorrhea from 
chronic endometritis. Leopold holds that this is a very common 
cause of i)ruritus; also leucorrhea from vaginitis, as in gonorrhea, 
is a not uncommon cause of itching. 

(6) The urine of diabc^tes is a frequent cause of pruritus. The 
patient complains of groat thirst, drinks large quantities of water, 
and is hungiy most of the time. Examination of the vulva shows 
slight redness about the orifice of the urethra, rechiess and perhaj)s 
induration of the labia, and excoriations from scratching. The 
urine has a sweetish smell and on examination is found to contain 
sugar. Pruritus is often the fii-st symptom which leads to the 
diagnosis of diabetes. 



(c) The urine of cystitis, or nephritis, may cause pruritus, but 

Ithis is not a eoninion haiJiMiiing and usually yields readily to treats 
'nient for the urinary ilifFirnlty. 

3. Diseases of the vulva rausing pruintus are, first, (a) congestion 
of the vulva and varix of the vulva, botli commonly found in preg- 
nancy, in uterine or ovarian tumors, or in any ol>stru(*tion to the 
vt.*nous nj^tmii of the bItXMl in th<^ pelvis,-— sufii as intra-abdominal 
pressure on the vena cava. Even the congestion of the menstrual 
pctriod may be* accompanitxl by it(*hing. 

(fc) Vulvitis and kraurosis vulvae are attended by more or Ic^ss 
pruritus, the latter, generally by mtense itching. 

(r) Pediculus pubis is a cause of itching. On careful inspection 
of the hairs of the \qilva the parasites or their nits are rea^lily seen 
and are de.stroyt^l by shaving the parts and ancinting witli a ten- 
per-cent solution of carbolic acid and olive oil. 

(rf) Thrush of the \iilva is a cause of pruritus, and in httle girls 
(e) simple uncleanliness seems to operate as a cause, (/) Eczema 
of the Milva is nearly always attended by severe itching. 

3, Neuroses.^ — Untler this head we may hiclude, (a) ma^turha- 

Ition, although it is doubtful whether the itching is not the cause of 

f the masturbation, rather than the reverse. There can bt^ no iloubt, 

however, Imt that constant handling and irritation of the clitoris 

and vulva make for hypersensitiveness and therefore exaggeration 

of a predisp^isition to pnu'itus. 

(b) Oxyuris vermicularl*^, or pin-worms, found in the rectum in 
children, cause itching not only alx)Ut the anus but of the vulva 

In finiritus vulvie in a child this cause, as well as uncleanli- 
s, should Ix' always souglit fur. 

(c) Pruritus is conmion at the menopause without discoverable 
lesions of the vulva ^ and is observed sometimes also in (d) women 
having a rheumatic diathesis. 



n 



PART II 

SPECIAL DIAGNOSIS 



CHAPTER XI 



THE DIAGNOSIS OF ENDOMETRITIS, INCLUDING 

GONOHRHHA AND EROSIONS OF THE 

UEHVIX UTERI 

Aiuitomy and [ihysiology of the efidoiuelrium, p. 166, 
Pathology, p, HJJK 

Aniiiowiico-piilhological chissifiealioii. p. 170, 

Endunietrifis from a diiiical point uf view, p. 17!l: Acute non -gonorrheal 
rndonietfitis, p. 173: Etiology, p, 173; S>^Tlptoms, p, I7i; Signs, jk 17ti. 
Ulironic non-gimorrheal endotne Iritis, p. 170; Varieties, p. 176, (1) Of 
puerperal origin, or [)ost-ttlMjrtiirn, p. 176, (2) Those varieties which are not 
prectxled by a known acute stage, p. 177; Etiology, p. 177; Symptoms, 
p. 177; Signs, p. 178. Gonorrheal endometritis and gonocoerns infii'tion, 
p. 171i, Acute gonorrheal endometritis, acute gonorrheal emlocervifitis, p. 
180; S^TTiptoms, p. 181, Diagnosis, p. 181, Differential diagnosis, [j. IHl; 
Chronic gonorrheal endoinetrilis, p. 18*?: Ljitent gonorrhea in women, 
p. 182; Differential diagnosis of chronic gonorrheal endometritis, p. 1H,*1. 
Senile endometritis, p. IKK Endoc*ervidtis, p. 184. Erosions of the (^rvix 
uteri, p. 184: Characteristics, p. 184; Diagnosis, p. 185; Differential 
diagnosis, p. 186. 

Alihough endoiuetritls is a part of tlic inflammatory^ process 
callc^l Pelvic Inflanimation, it oiay exint without involvement of 
the i>eriiit^rine stnicture^, A» pelvic inflamniation is most- often 
rau.sf*il by infection introduced thnjugh the vagina and utcms, so 
endometritis is generally a Ix-ginniiig stagi* of pelvic inHanimation. 
Tlie term endmneiritis will \w used to define inflaiimmtioa of the 
endometrium. 

Entlocervicitis is the name given to the inflamnmtory process 
whi*n it is liniitetl to thf* cervix. The flilTerentiation of endocer- 
vicitis from enilometritis of the body has a i>ractica] importance 
in the acute infections, es|)CTially m gonococcus infection , and 
abo in the chronic form of inflainntation wherry the disease is aj^t 
to be situatfHl chiefly in tlie rervical canal An inflammatory 
prcxreas Httuated in the entlometrium may c»xtend to the muscular 
i?tructurc of tfie uterus, and then the process may Ix' defined more 
tly as a metritis. 

In practice the diagnosis of metritis aside from endometritis 

165 




166 



THE DIAGNOSIS OF ENDOMETRITIS 



is an academic affair and of no practical significance even when 
it is possible to diagnose one without the other; therefore, little 
will l)e said of metritis, with the understanding that in the seven* 
grades of endometritis there is present also metritis. 



ANATOMY AND PHYSIOLOGY OF THE ENDOMETRIUM 

A word as to the anatomy and physiology of the endometrium 
l^efore taking up the consideration of the (iiflferent manifestations 
of inflammation. The following description applies to the un- 
impregnated uterus of the healthy adult woman between menstrual 
periods. It will be noted that the mucosa of the cervical canal 
is anatomically and physiologically different from the mucosa of 

the uterine cavity proper, therefore 
we are justified in considering the 
word endometrium as applying to 
the latter only. 

The interior of the uterus is 
divided into two cavities: the cavity 
of the body, and the cavity of the 
neck, which are separated from each 
other l^y the constricting ring of 
muscular tissue about the internal 
OS. The shape of these cavities has 
been referred to elsewhere, the cav- 
ity of the l>ody being represented by 
an inverted isosceles triangle with 
the two angles of the base in the 
uterine cornua and the third angle 
at the internal os. The anterior 
and posterior walls of the uterus 
meet at the sides at an acute angle so that there are no lateral 
walls i)roi)er, therefore the uterine cavity is flattened from before 
backward. The cervical cavity is fusiform in shape, largest in 
the middle and contracted at the internal and external ora. 

Under resting conditions the cavity of the body is closed against 
infection from Ik'Iow at the internal os and from infection from 
above by the muscular constrictions at the isthmuses of the Fallopian 
tubes. The cavity of th(? ccTvix in like manner is protected from 




Fig. 64. — Reconstruction of 
Uterus, Showing Shape of Uterine 
Cavity and Cervical Canal. (Wil- 
liams.) 



ANATOMY AND PHYSIOLOGY 



IGT 



mfection from above by the narrowing at thu inttTnal o.s, and frurn 
below in the nullipai'oiLs uterus more, and in the parous uterus 
less, by the conslrietion at the external o8. 

The wall of tlie uterus is niarle up of thi'ee layer's, the thin^ serous, 
jx^ritoneal layer, the tliiek iimscular layer — oom|>o8ing most of 
the structure of the uterus — and the rnodium thick mucous layer. 
The mucous layer, the endonietrium, eonsists of the utricular 
glauils, connective tissue, blao< I- vessels, nerves, and lymphatics. It 
is covered by a single layer of ciliatcii columnar epithelium — which 
aJso lines the glands — and is coutinuetl through the Fallopian tubes. 



^ V''^-'-?= ^cA 



5^. 



Fio, 65,— Normal Eodometrium, 



(WUliams.) 



The endometrium is essentially a glandular structure. The 
glanris arc tubular and branching, several opening often by one 
mouth. They extend into the muscular layer and all o[»en into the 
^Uterine cavity. In the bo^ly of the uterus tlie endometrium Is 
rifjecly united to the muscularis, whereas in the neck it is fn^er. 
In the cervix uteri the lining epithehum shades into pavement 
epithelium at the external os. In this cavity the mucous mem- 
brane Is thrown into olJique ridges which diverge from an anterior 
and posterior longitudinal ra|)he, presenting an appearance which 
has received the name of arl>or vitse. 



168 THE DIAGNaSlS OF ENDOMETRITIS 

The normal secretion of the uterine glands is a clear, watery 
fluid, having an alkaline reaction, that of the glands of the neck is 
clear and viscid; it is also alkaline. Throughout the cervical 
mucosa are found a variable number of little cysts, presumably 
glands, which have become occluded and distended with retained 
secretion. They are called the ovula Nabothi, or Nabothian 
follicles. 

The endometrium shows normally many differences in structure 
from infancy to old age and during the intermenstrual and menstrual 
cycles. 

Before puberty it is relatively thin and undeveloped, nearly all 
of it having the character of the cervical mucosa. 

Our views as regards the normal histology of the endometrium 
have of recent years undergone a considerable change, due to th(» 

important observations of Hitschmann and 
Adler {MonaU^sclmft fur Geburts. und 
GynaekoL, 1908, XXVII., 1), confirmed 
by several subse(iuent investigators. 

Hitschmann and Adler, after a painstak- 
ing study of the uterine mucosa from fifty- 
eight women at various periods of the 
,, ^^ A7- • 1 17 * menstrual cycle, found that the endome- 

tio. bb. — Virginal Extcr- '^ ' 

nal Os. (Williams.) trium from the c(\st<ation of one menstrual 
flow to that of the next, presents a con- 
stantly changing histological picture. This cy(!le of changes they 
divide into four phases; postmenstrual, interval, premenstrual, 
and menstrual. At the height of the menstrual flow the nmcous 
membrane diniinish(\s in thickness and the glands pour out their 
secretion, l)econiing narrow and straight. The surface epithelium 
is freciuently lost, but this is not an invariable rule. After the 
period th(T(^ takes place a very rapid cell growth in both the 
epithelium and connective tissue. The glands Ix^come larger and 
wider, although still quite narrow and straight. The epithelium 
is low and in a condition of rest. By about the fifteenth day the 
cell growth of th(^ e{)itheliuni has progressed to such an extent that 
the glands bcH'ome somc^wliat tortuous, and often assume a spiral 
or corkscrew-like app(*arane(\ Finally, six or seven days before 
the l)eginning of menstruation, the glands rapidly enlarge and 
be(»ome tortuous, the colls Inilge into the lumen, the epithelium 



> w 



PATHGIOGY 



im 



becomes higher antl broatler, ami thv luiucii is filled with a 

mucous secretion. Thcise gland changes are much more marked 

in the dee[HT jK>rtioii of tlie nuicosn than in the superficiah su that 

there is produced a well-marked differentintioo into a suiierfieial 

rompaet and a deep spongy layer. In this 

respect there is a marketl t^imilarity to 

the ap[>earanee of the young decidua, thi^ 

resemblance lx*ing increa.sed by the fa(*t 

that the mterglandular stromal cells in 

many cases assume an a]>pearance very 

similar to or approaching that of decidual 

cells. 

During pregnancy the mucosa of the cor- 
pus uteri is enormousiy congested. Its 

function is the formation of the deeidua — the connectives tissue 
cells of the endometrium going to make the decidual celk of 
pregnancy* 

Following the menopause there is an atrophy of the endometrium 
coiuciiient with th«" sluinking of the uterus so that in the old 
woman the uterine glands are foimd almost t ntin^ly obliterated, 
And there is apt to lx» partial or complete closure of the uterine 
canal at the internal as. 



Fig. 66a.— Parous Exfer 
nal Os. (Williams,) 



PATHOLOGY 



It is probable that all forms of endometritis are due to bacterial 
invasion of the endometrium. The endometrium under normal 
conditions is sterile, and bacteria in small numlx»rs introduced 
from without are promptly destroyeil. Although clR-mical irrita- 
tion and trauma may cause congestion and favor bacterial growth, 
the idea that these influences and ** constitutional taints'' do any- 
tiling more* than provifle a fertile sfiil for the microorganisms has 
gone the way of many older theorie^s. 

The following l>act^ria have Ijeen found in the endometrium in 
cases of endometritis — seldom in pure cultures, generally in mixetl 
infections:^ 

Staphylocwcus pyogenes albus, citreus, and aureus. 

Streptococcus pyogenes, 

Gonococcus. 



170 THE DUGNOSIS OF EXDOMETRITIS 

Colon l)acillus. 

Tulx^rclo bacillii?. 

Diphtheria l)acillus. 

Typhoid l>accilliis. 

Pneumococcus. 

Bacillus aerogenes eapsulatus. 

Spirochivta pallida of syphilis. 

In many forms of cndomotritis the bacterium reaches the endo- 
metrium from without by way of the vagina; in a smaller number 
of varieties it comes from the Fallopian tulx^s or abdominal ca\'ity 
through the lum(*n of the tulx*s: and in still other varieties it conies 
through the lymphatics and veins of the uterine wall from near-by 
sources of uifection in ix^ritoneum, rectum, or bladder: and rarely 
it reaches the endometrium from distant sources through the blood 
current. 

The classification of endometritis has long been a stumbling 
block to the gj-necologist. A recent writer on the subject gives a 
pathological classification containing eleven different forms, accord- 
ing to the macroscopic or microscopic ap|)earances of the different 
varieties, and a clinical classification of ten different sorts of clironic 
endometritis. 

A l)acteriological classification will ultimately Ix* the one chosen 
as a guide to diagnosis. At pr(\^ent, not enough facts are known 
to justify its use. As it is im|)os>il)le to diagnose the different 
varieties according to the pathology, except by examination of 
scrapings from tlu* endometrium, and, according to the presc*nt state 
of our knowledge of th(» pathology of the endometrium, the differ- 
entiation of th(^ varieties has no Ix^aring on the treatment, we shall 
consider tlu^ subject from the (»Iinical point of view. Suffice to 
mention the forms of (endometritis which have been recognized as 
a result of the micr()sc()|)ic examination of scrapings and of uteri 
removed by operation. 

ANATOMICO-PATHOLOGICAL CLASSIFICATION 

Hypertrophic endometritis ^ in which the endometrium is thickened 
and soft. If the glands are incn»ased in size only, it is called 
hyjKrtrophic cjlamhilar emlotnetritis^ if they are increased in number 
it is called hyperplastic glandular endometritis. 



AN ATOM WO- PAT HUH Xi ICA L TLAHS I FICAT ION 



171 



F. Hitsehniann ami I., AdltT (ZeU. f. (kbs, il Gun,, 19U7, LX., 
63) gtate timt (^ndoinrtritis glaiMlularis hyiM-rtrophira ami ciuI<h 
niPtritin ^landiilaris hv[MTpIaHtica have nothing what80i*vcr to ilo 
with inflaiiynatioii. The hrst Is not cvvn a |>HtlioloKit'al contlition cif 
thr ntrrin** rnurosa hut eorro.^ponds to the [^rcnionstnial Ktatr of the 
nonnal lining of thp uti^ms; the latter eonsist^ partly of the normal 
|>renu*n.*itriial ronditinn, anci |jartly of vaiiatiniis in thennrnher of 
glancis within phyHiolo^ic^al hoiits; in addition it inr hides eases in 
wliieh there in a glantlular hyi*ertro|)liy of the uterine mucous 
nieinhrane, but thi^ ato is a change which is entirely independent of 
inflammation. 

There i^, accortiing to these investigators, but one variety of 
inflammation of the uterine mueoisa, endometritis interb-titialis, or, 
a.s it is usually ealled, en- 
rlometritl*, Tl le < I iagt losis 
18 TLiaAle by demonstrating 
the cells of infiltration, so- 
eallt^! plasma cells. 

If the inflamnjator)' proe- 
e8J* alTt*cti5 cliiefly the inter- 
glandular connt»ctive tissue 
the i>rt>ces8 is kno^n as in- 
terstiiiat endometrium. This 
fonn lias an acute and a 
chronic Ftagc, the acute 
lR*ing characteriztMl by dif- 
fuiio or circumscribed infil- 
tration of tlic stroma by small round cells with congesftion of the 
l>loo<l-ve8H<»ls and a serous exutlate in the spaces of the connective 
tissue (exudative interstitial endometritis). Tlie chronic stage Is 
cliaracterized by newly fornKsl connective tissue resulting in com- 
[m-siqon of the utricular glands, and, in the later stages in atn*pliy 
t>f tlif»enc!ometriimit theso-cidled atrophic cmioffietriii^'i. 

Retention cysts may \w fomu^d in the interglandular spaces of the 
connective tissue and ri/fitir interstilial endometritis results, or the 
glarals may Ix* oljstructec! by the (>res><ure of the connective tissue 
at their mouths, cyf^tic i/landulnr efidfnnctritis, Fungoii>( endome- 
triiiM \» the term appliiHl when tl»e uiucosa is thrown into folds; 

Uqu» endontetriiis, when it in covered with shaggy villosities; and 



Vui. G7. — Horizoutai Sectkiii of the Tp- 
p<.vr Part of the Body of tlie Utenis. 





triurn — as in carcinoma and tuberculosis— the process is called 
idcerative endojjwiritis, 

Decidnal endometritis is the name given to inflanimatton of tho 
endometrium during pregnancy. It h diagnot^etl dcfinit<»ly by 
microscopic examination of the decidua after expulsion of the fetus. 
Evidences of inflammatory action are present. The h-ymptoms 
may Ixr hy(h*orrhca uteri gravidi, or pains in the uterine region 
during pregnancy. 

A rarc^ condition is exfolmtive endometritiSj so-called memhmnmis 
dysmenorrhea. It consists of the discliarge from the uterus of a 



I 



ACUTE NON-GONORRHEAL ENDOMETHITI8 



173 



rKn 
othi 
It i 
tub 



more or less incomplete cast of the ca\ity of the corpus uteri, in 
the shape of a sac, triangular in form, gray in color, and of a rough 
surface. Floated in water and laid open, its interior is smooth. 
When examined undrr a nm^^nifyuig glass it is seen to Ix; .studded 
with minute openings \vhi(*h rrpresc^nt the mouths of the utricular 
glands. \\Tieji the sac is reaisonably complete the openings of the 
Fallopian tub€\s may \yc rlistinguished at the upi>er angles of thi* 
hae. The membrane is from one to three millimetei-s tli!<'k ancl 
under the microt^'oix^ shows much the appearances of exudative 
ifiterstitml endomeiritw^ although the pathological appearances vaiy 
in different cases, 

Tubertulom emlmneiritiH, relatively rare, is a sequel often of 
primary tuberculosis of the tulxs. Rarely it is primary in the 
eemx. TuIktcuIous infection may rencli the endometrium also 
from without by coitus, or ljy instrumental or digital interference. 
Occurring in the late stages of general tutxrculous infection of the 
ito-urinary system, it has no clinical im[X)rtance, tx^causf* the 
'other manifestations of the disease are of overshmiowing seriousness. 
It i^ characttTized by the prt^sence of giant cells, tulxTcles, an*! 
tubercle bacilli fomid microscopically in scrapings made from the 
endometrium. The tulxTcle bacilli may Im* detectefl in the uterine 
dL^harges. Many cover-slip pivparations ishould bt^ studied before 
affirming the absence of the bacnllus. 

Not much is kno\^Ti of tlie forms of endometritis occurring after 
the acute infectious dis<*a.ses^typhoid fever, diphtheria, scarlet 
fevcT, measles, and smallpox — nor of the endometritis which 
attendi* syphilis. 

Gonorrheal endometritis will be con.sideretl separately under the 
eljBJeal clarification. 



ENDOMETRITIS FROM A CLmiCAL POIIfT OF VIEW 

The subject Is b<'st divided into nrule and chronic eiidometrilis^ 
with sjM^cial coi»sideration of (jonorrheal endometritis, sefiile endmne- 
iritis, and endoceTriritis. 

ACITTE NOX-OONORRHEAL ENDOMETRITIS 

Etiology.— This is an inflammation due to inva^sion of the 

idometxiuiu by septic microfirganisms, more especially the 

lylococcuB and the streptococcus. It is a grave form of en- 



174 THE DUGXOSLS OF ENTX)METRm3 

(lonietritls a^ eontra.<tcil w\xh a majority of the chronic forms of en- 
riometritis, wliich are of a miki tj-pe and have no recognizable 
acute stage. 

lx< chief caase:? are: i 1 1 infection following labor and abortion; 
(2; the a<e of uncleanly fingers or instruments in making office 
treatments: «3) oiH»rations which are not aseptic, and (4) sloughing 
intra-uterine tumors. 

(1) Infection following lal)or and abortion is the most frequent 
cause of acute endometritis. It can not be entirely avoided even 
with the most scnipulous can*. Retaineil membranes may de- 
compose and cause it. Too often the phj'sician is to blame. 

Bacteria brought to the vagina .on carelessly washed hands, lack 
of thoroughnc^ss in the preparations for the immediate repair of 
the injuric^s of the jX'lvic floor and piTineum following labor, the 
unn(M;e.ssar>' use of forceps, or too fret[uent vaginal examinations, 
to say nothing of too much doucliing — thereby washing away 
the nonnal si»c»rt*tions of the vagina, which, according to Doder- 
lein destroy pathog(»nic l)acteria — all play an important part. 
The great danger of so-call(\l s<'ptic endometritis, which attends 
criminal alx)rtion, is tfx) well known to re<[uire extended comment. 

(2) The general practitioner of mcnlicine, realizing the necessity 
of washing his hands after an examination, is cart»less about washing 
them Ix'fore making a vaginal examination or instrumental treat- 
ment. The practice of making intra-uterine office treatments is 
dangerous even with strict asepsis, Ixsides lx*ing useless as a 
therapeutic measure. Passing the sound into the uterine cavity 
should Imj done only under strict aseptic precautions and iiith the 
utmost gentleness to avoid trauma. 

(3) Minor operations may cause as great harm as major ones and 
too commonly do so Ix'cause tlu* preparations for the lesser pro- 
cedures are not as can^fully made. 

(4) Sloughirig of a uterine polyp, of a pedunculated submucous 
fihroid, or of an inverted uterus sometim(»s results in septic endo- 
metritis unless prompt oju'rative measures are instituted. 

Symptoms. — TIk* symptoms of acute endometritis with septic 
absorption, acute .vc/>//r ettdonietriti.'^, manifest themselves within 
twenty-four to forty-eight hours after hif(H*tion, although they may 
be delayed for several days. Their severity depends uix)n the form 
of infection. A septic intoxication which is due to the absorption 



ACITTE NON^ONORRHEAL ENDOMETRITIS 



175 



iiiio the system of ptomames, — the* product of decomposition set 
up by bacteria, — is calkxl mpremm; that wliieh is due to the 
alisorption of the bacteria themselves with their toxins is known as 
^seiduefnia |irojx*r. As yet vv(* have no nit'ans of drtcirnining wiiich 
form of infection is prt^ent in any given eas(^ We know that the 
form caust^d by th** streijtoeoecus is the more grave, that the 
streptococcus may Ix- chfTustMl very rapitlly throughout the system, 
ttud that in dt*ath irsuhing from this form tliere may h(* found few 
pathc»logical changes in the iK*lvic organs. The staphylococcus, on 
the otlifr hand, is more aj^t to jiroihiee marked loral ren<'tion and 
pus formation. The severity of the symptoms will vary acconhng 
to the eontirmcHl presence of the soiux'c of infection anti the rat>idity 
of its al^sorption. Although the endometrium is the point of en- 
trance of tlie infective material into the system and endometritis 
is the first manifestation of the poisoning, tlie tlisease is a general 
one almost from the first, In the later stages of the disease* the 
involvement of tissues neiglilM>ring to the endometrium — the uterine 
tnui^cle, p<»lvic cellular tissue, the Fallopian tubes, ami peritoneum — 
produces complications which overshadow the enilometritis. The 
symptoms are ushered in by a st*vere chill, followed by elevation 
of temj>erature (103°-1(H° F. or higher), and a rapid pulse (lllK 
120 or higher). If the disc^asr follows labor or abortion the lochial 
di^harge is diminishtnl in amount at fin?t and then increat*ed, tH> 
comes dark in color, tiien [>mHilent,and generally, though not in the 
.stn^ptococTic form, has an offensive cxlor. If the disease tloes not 
follow Ialx>r or al>ortion a blf>o<ly, purulent, usually offensive uterine 
di.scharge is a constant symi)tom after the initial chilJ. Intermitti'iit 
uterine pains^ — tjeeoming eontiimous and sev<vre if the inflammatory 
proc«?ss nmches the peritoneum— naus4^^*a, const ii>at ion, and freiiu**nt 

tWtU painful micturition are early symptoms. 

Irregularly ix'<Hirring chills, high temix^rature, rapid and fet^We 
pulse, a sensi' of welMxing and apathy, the eliaracteri.stic un- 
dt??scrifx*<l cnlor of s4L*psis, iliarrhea, and failing strength, are symi)tonis 
of the advanced stages of the disease. 

AmU; tridorftetritis iritlntuf mjfremia or tn'idiceffiia, is attended l»y 
comparatively slight constitutional distiu'lmnces and the syirijjtonis 

'lUv linuti*il to elevation of temjXTature — generally pnvtnled by a 
cliill— pain of mo«lerate s<:verity in the lower alMlomen, fre*juent 
and painful micturition, nausea, and disturbance of menstruation,^ 



176 THE DLVGNOSIS OF ENDOMETRITIS 

either suppression or menorrhagia. The symptoms abate in a few 
days. 

Signs. — In all forms we find on physical examination, — ^the uterus 
enlarged and soft, tender to light pressure in all parts; the vagina 
hot and dry; the uterine discharge wanting at first and later 
mcreased in amount. The os is patulous. Rigidity and tenderness 
of the abdominal muscles, called peritonismus, is to be expected 
if the peritoneum is involved in the inflammatory process, other- 
wise not. Acute endometritis without complications is uncommon. 

If the case is seen early an anesthetic should be given because of 
the great pain caused by manipulation. Thorough aseptic precau- 
tions are observed. A sound is passed into the uterus and retained 
membranes, or sloughing tumors, polypi, or fungosities are detected 
by sound-touch. In cases of doubt the cervix should be dilated 
until it will admit the operator's finger, and the interior of the uterus 
explored by touch, all adventitious tissue being removed either 
with the finger, curette, or curette forceps, and preserved in a ten- 
per-cent formalin solution for microscopic examination. 

Chronic Non-gonorrheal Endometritis 

Varieties. — Chronic endometritis may be divided into: (1) those 
forms of acute endometritis that have terminated in a chronic form, 
and (2) the varieties w^hich present no acute stage demonstrable 
by clinical methods. 

(1) The forim of acute endometritis which have become chronic are 
commonly of puerperal origin, or postnibortum. Some of the 
pathological varieties are, — pscudodiphtheritic, decidual, and 
ulcerative endometritis. A chronic endometritis resulting from 
an acute s(*i)tic endometritis generally has as complications one or 
more of the following affections: — metritis, cellulitis, peritonitis, 
pelvic abscess, or salpingitis. When the inflammatory process is 
centered (chiefly in one of the situations just enumerated, the in- 
flammation of the (endometrium is less active and the physical signs 
indicate that in the endometrium the fire has, as it were, burned 
out, leaving only smouldering embers. Microscopic examination of 
the endometrium n^veals one or more of the different stages of 
glandular and interstitial endometritis as described on pages 170 
and 171. 



CHHONIC NONMIONOHEHHAL KNDOMETRITIS 



177 



If st^ptiecmia is present the .syTiiptoins are those of dironic 
L6c*pticeiiiia; fluctuating rlcvations in the tenitieraturej rapitl and 
feeble pul.se, (U-y i^kiii, diarrhea, the oilor of sepwis, niahiutrition, and 
anorexia. 

There being no septieeniia the symptoms are leueorrliea^ uterine 
heruorrhage*s, rneni^trual di.sturi)anees» dyspareunia^ t^terility, antl 
|abr»rtinn, and .symj>toni8 referable to the digestive and nervous 
rstems. 

I^ticorrhea is the oidy constant symptom. The discharge is 
profuw<% — though varying in amount in individual causes. It is 
purulent in character and may be mixed with blood. It is, as a 
rule, odorless urdess it has Ix'en retained on the vulva and has 
iIeconi[>os4*<l IxTause of the jiatient's uneleardy hal>its. 

A liistoiy of an acute attack of septic infection and the character 
of the leucorrhea — e^jx^cially if septic mirrourganisms can be 
found in it u|)on microscopic examination of cover-glass prepara- 
tions — servT to distinguish tliis furni of imtlometj'itis from 

(2) The large number of varieties of chronic endometritis which are 
not preceded by a hunim acute stage. They may Ix* enumerated 
iBs: — fungous, villous, polvix>id, exfoliative, and tulxTculous. 

The endometritis of the infectious diseases — tyfihoid fever, 
diphtheria, scarlet fever, measles, small-pox, and syphilis— all 
arr^ of a mild type. 

Etiology.— Predisposing causes of chronic endometritis are:^ 
uterine displacements, uterine malformations (espwially ante^ 
flexion), subinvolution of the uterus, extensive lacerations of the 
ueervix, tumors of the pelvis, sexual excesses, chronic constipation. 
Ihe infectious disc*asf\*^, and certain constitutional diseases,— anemia, 
chlorosis, rheumatism, and litheniia. 

The pathological process<^»s i>resent are glandular and interstitial 
endometritis as tlescrilx?<l on pages 170 and 17L 

Symptoms.— The chief symptom is leucorrhea. The patient dot^s 
not remembf^r when she firsi. noticed a vaginal discharge, so gradual 
is its beginning. It is due to the secretion of the utricular glands 
plus that of the vulvo-vaginal glands. The amount depenils on 
the condition of the enilometrium,^niore when it is hypertroirhieil 
and in the glandular variety of endometritis, and les*^ in the atrophic- 
variety. In tlie fungous ami |Hjly|Kjid fnnns (he leucorrhea is apt 
to be bloody, and, if there is decomposition of tissues, pui*ulent. In 
12 



178 THE DIAGNOSIS OF ENDOMETRITIS 

most of the varieties of chronic endometritis the discharge is thin 
and serous in character. 

When the secretion from the cervical canal exceeds in amount 
that from the body of the uterus the discharge is thick and 
viscid in consistency. It is without odor and is unirritating as 
a rule, although in patients of uncleanly habits it may have a 
foul odor. 

The amount of discharge varies from a staining of the linen to 
several well-soaked napkins a day; it is increased for a day or two 
just before and just after each menstrual period because of the 
normal congestion of the genital organs at these times. 

Hemorrhage at the menstrual period or excessive menstrual 
flow — styled menorrhagia — is to be expected in the hypertrophic 
form of endometritis; scanty flow in the atrophic forms. Painful 
menstruation — dysmenorrhea — is a pretty constant symptom, 
although it occurs in such great variety of manifestations and at 
such variable times with reference to the flow that it is impossible to 
dogmatize about it. Irregularity in the occurrence of menstruation 
also is to Ix^ expected, variations of a few days before or after the 
normal time being common. 

Sterility and abortion are more often observed in patients suffer- 
ing from chronic endometritis than in women with nonnal uterine 
organs. Sym{)tonis of gc^neral ill health usually accompany chronic 
endometritis, although it is not always easy to determine whether 
the ill health is due to the endometritis or the endometritis to the 
ill health. 

Signs. — ^The physical examination reveals a uterus enlarged, but 
not necessarily to a marked degree, and more or less sensitiveness 
of the uterus to light pressure when it is scjueezeil between the ex- 
aminer's fingers during the combined vagino-alxlominal or recto- 
abdominal touch. If the uterus is occupied by polypi it will be felt 
to be fatter than normal, and often a polypus, having been elon- 
gated and driven down b}^ the uterine pressure, presents at the 
external os. 

On speculum examination a discharge is seen to be issuing from 
the external os. Its character is noted. A tough stringy mucus 
is the characteristic of the secretion of the glands of the cervix; 
a thin, watery discharge is from the glands lining the cavity of the 
corpus uteri. The alkalinity of the discharge should be tested 



ENDOMETHITIS AND GONOCCKX'US TNTECTrON 179 

wth a piece of litmus paper. In t'ndoinetritis the reaction is often 
neutral or even arid. The eondition of the neek of the uterus is 
noteti, — whetlier laeerateil rjr enxlcHl or not. 

On |>a^i*ing the uterine .^oiind the eavity of the uterius i.s generally 
found to be enlarged. In anteflexion with en<lonietriti8 the in- 
ternal as 18 tight, Imt the o|HTator will find that hy straij^htening 

[tlM! canal by traction on the cervix with a tenaculum it i.s alway8 
Bible to pass a sound of small ealilnT*, Previous to passing the 

( Founil an accurate idea should Ix? olitained as to the probal>le 
(liiti'tion of the uterine canal by means of the bimanual touch. 
Great gentleness i.s esjsential 

If the sound is {>assed witli t!ie greatest care and blotKl flows after 
it** withdrawal and the cavity is tender, endometritis may Ik* 
diagnoseil Fnngosities and pt*l}'j>i are to Ix* detectwl in favorable 

I caf^CB by the tactile Bensc^ transmitted through the souiuh ie., when 
the canal is iiidely ojx'n and reasonably straight. Points of ten- 
derness in the endometrium and their definite situations are deter- 

^ niltial by the sound. 

GOXORRHEAL ENDOMETRITIS AND GONOCOCCUS INFECTION 

Gonorrheal endometritis merits spc*eial consideration lx*cause it 
^18 a very common di^ai^ and has serious sequehe. 

As to its fn^iuency autliors ilo nf>t i^rnr. It is midoid^tedly 
more common in the public clinics and among prostitutes than in 
private practice. Zweifel estimated that ten |ier cent of his private 
gynecological cases suffered from gonorrhea. Different WTiters 
place gonorrhea as the eaus4^ of acute inflannnation of the uterus 
and tubes in from one-half to two-thirds uf the patients sc^en in the 
tU^Ix'nsary st^rvices of the large cities. Tliiif estimate includes 
J some of the pti(T])eral eases, which form a considerable number of 
the total acute infections, for the gonocoecus, as well ius the stajthy- 
lococcus and the stn^i^tftcoceus^ is the cause of puerperal infection. 

The gonocoecus, a diploeoecus diseov(Ted by Neisser in 1879, 
fiiids a favorite habitat in the deejxT {Kirtions of ihr mucous mem- 
bmnoH which are coverc^d with cylin<lrical (Epithelium. It also 
jrrows n-ailily untler pavement epithelium, but can not jienetrate 
the .s<|UamoiLs epithelium as easily as the columnar. 

Its favorite homeii in the female generative apparatus when once 



180 THE DIAGNOSIS OF ENDOMETRITIS 

introduced are, in order of frequency:^-(l) the urethra and 
Skene's and Bartholin's glands; (2) the mucosa of the cervical 
canal; (3) the upper portion of the vagina; (4) the endometrium 
of the corpus uteri ; (5) the mucosa of the Fallopian tubes. 

Although the squamous epithelium of the vagina of adults, 
bathed in its acid secretions and protected by its normal bacterial 
flora, resists the invasion of the gonococcus, the tender vaginal 
mucosa of children, although covered by squamous epithelium, is 
easily penetrated by it, whence the frequency of vulvo-vaginitis 
among children. 

The gonococcus is speeilily destroyed by other bacteria and their 
toxins in the case of a secondary infection in the process of abscess 
formation, as attested by the rarity with which it is found in the 
contents of a chronic pyosalpinx; on the other hand it may remain 
alive in the mucosa of the cer\'ical canal or in Skene's glands for a 
series of years. As a rule gonorrheal infections are uncompli- 
cated by mixed infections with other bacteria unless trauma 
accompanies the infection. 

The diplococcus is always introduced from without — in little 
children by the contaminated fingers of an adult infected with the 
diseases and by soiled linen or bath sponges — in adults, as a rule, 
by coitus. 

Gonorrheal endometritis invariably begins in the cervical canal. 
It may be liniitcMl to the cervix uteri if the internal os is well closed, 
— as in virgins and in anteflexion. In multiparous women it is 
prone to spread to th(» corpus uteri. Sometimes the gonococcus is 
carried from the cervix to the corpus uteri by the physician's sound 
or uterine applicator. The disease is acute or chronic. 

Acute Gonorrheal Endometritis 

The disease is limited to the cervix, acute gonorrheal endocer- 
vicitis. The mucosa of the ccTvical canal is reddened, swollen, and 
bathed in pus, which sometimes has a grei»nish tinge. The neck is 
swollen, soft, and tender to the touch. Examined histologically 
the mucosa shows loss of (epithelium in places; the uterine glands 
show hypertrophy and liyiXMplasia, and the interglandular tissue 
is (»normously infiltrated with rounil cells and polymorphonuclear 
leucocji:es. The blood-vessels are increased in number and size. 



I 



the epithelial t*dls and also in the subepithelial tissue. The 
gonwocci may also bi* fountl in the pus. They seklurn penetrate 
the utr'rine niu.scle hy way of the lyni|ihatics as do tin* stre|>toeoeri, 
anil when gonorrheal inflaniniation reaches the jx^ritoneuni it rloes 
8o by way of the mucosa of the corpus uteri and of the Fallopian 
tubes. 

Symptoms. — The symptoms of aeute gonoiTheal endocervieitis are 
generally marked by the symi)toms of coineident inHatnmation in 
the urethra, vulvcvvaginal glands, and vagina. There is a history 
of inAx-tion. The s\inptonis art* ushertxl in by a ehill followeil by 
an elevation of temptTature and a ra]^id pulse. The patient com- 
plains of pelvic jmin, painful micturition and defecation, nausea 
and vomiting^ and, in the course of a few hoiirs, there is a leucorrhea, 
— at first nnicous in eliaraeter, soon becoming purulent and some- 
timi^ mixed with blotwL Tlie sym|>t(*ms are not st> severe ws in 
acute septic endometritis, and la.st not over a wei»k. They are more 
prt>nouneiH| if tin* iiiflanujiation !ias extended to the body of the 
uterus, and still mon* so if to the Fallopian tulx*s. In these cases 
one look^ for gnmter pelvic and ablominal pains. 

Diagnosis. — The diagnosis rests on (1) the history of a suspicious 
intercourse:*, which was followeil by a i>urulent vaginal discharge, 
and by prec^xling fre<|uc*nt and painful micturition, Le., an acute 
urethritis, strong proisumptive evidence of gonorrhea: (2) the 
symptoms ju5t cmumeratcMl; (li) the physical signs. The cervix is 
swollen and t^nrler, and i>us flows from the os. If the nmcosa of 
the corpus uteri is also involved — acuite gonorrheal endometritis — 
the entire uterus Ls enlarged and tenfler to bimanual touch; (4) 
the microscopic examination of the pus shows tlie presence of the 
gonococcus. 

Differential Diagnosis.— The acute fonn of gonorrheal endome- 
tritis may be mistaken for aeute septic endometritis. In the 
^norrheal form the local anrl (constitutional symptoms are less 
Wvert*, there is lacking a cause for sepsis in the form of iJOw<t-puer- 
pcTal infection or intra-uterine treatment, anil on the other hantl 
there may be pres«nit a history (»f a suspicious inbTcou!*s(\ The 
urethra, Skene's glands, ami the \ailvo- vaginal glands are involved; 
thcTP may be enlargement of the lymphatic glands of the gnriin^ 
aflenitis^ bubo — 6iiaUy the gonoeot»ci are found iji the discharge. 




182 THE DIAGNOSIS OF ENDOMETRITIS 

Chronic Gonorrheal Endonietrilis 

Chronic gonorrheal endometritis may result from a well-marked 
acute gonorrheal endometritis. More commonly the history of 
an acute stage is wanting. The history of frequent and painful 
micturition, either following marriage or in a woman suspected of 
having loose habits, whether married or single, should lead the 
physician to consider the possibility of gonorrhea. 

The onset of the disease is generally insidious; the symptoms 
and physical signs are those of the varieties of chronic endometritis 
due to the saprophitic and pyogenic bacteria. 

The leucorrhea in gonorrheal endometritis is generally most 
abundant; it loses the purulent character of the acute stage and 
is mucous in character. The diagnosis depends on finding the 
gonococcus m the discharge from the cervix. Some authors claim 
that it is necessary to make cultures in order to identify surely the 
microorganism, but this view is not held by most. Many slides 
should be examined. Negative findings do not rule out gonorrhea, 
and this brings us to the consideration of latent gonorrhea. 

Latent Gonorrhea in Women. — Certain experiments by Wertheim 
of Vienna (Archiv. fur Gyn., 1892, XLL, No. 1), and clinical 
observations by a number of investigators, go to show that the 
gonococcus loses its virulence after a time — weeks or months — 
that when it is planted in new ground, i.e., when another indi- 
vidual is infect(Ml, the microorganism recovers its former vitality, 
and that when reintroduccnl into the original host all the symp- 
toms and signs of an acute attack of gonorrhea are manifested. 
For example, a man has acute gonorrhea which ends in a chronic 
gleet. He infects his wife and later is reinfected by her and has 
another acute attack of gonorrhea. In the course of time each 
becomes tolerant of the gonococci of the other. The husband has 
intercourse with a prostitute, suffers a fresh attack and reinfects 
his wife. This explains why the gonococcus, even after years of 
apparent cure, may regain its full virulence. Such authorities as 
Wassermann {Berl. Klin, Woch., 1897, No. 32, p. 685), Maslovski, 
DeChristmas, and JuUic^n agree that there is no immunity in gon- 
orrhea, one attack giving no exemption from the disease in the 
future. It argues for n^jjc^ated examinations of a gleety urethral 
discharge in the male before advising marriage. 




are IIk' rhit'f lurking |jla*'i'.s for the gnne^cuceiis in tlio fcnmlc gi^nital 
apparatus. 

Differential Diagnosis of Chronic Gonorrheal Endometritis* — 
Clironic gonorrheal (^ntiunirtritb mtiy Ix* uilstaki^Ji fop the j^iniplo 
fonns of endometritis. A gonon*heal «>rigin of an entiometritis 
may t>e sn^pectcnl from the history of tlie case;— an aeuto attack 
witli purulent dbcharge and painful rnieturitkm folknving a sus- 
j>ieioiis intercoui-si*. Occasionally there is a history of the patient 
having ha4:l a bulx) or gonorrheal inHaniniation of the joints. More 
conunonly no such history is ol>taiiialile. It is seldom advisidjle 
to in>rtitutc too nnnute inquiries in this direction in the ea^e of 
nmrriefl women Ix'cause of the risk of causing trouble between 
huslmn<l and wife, — trouble which can not Ix* cunnj by the physician, 

Tulml disease is found in conjunction with all forms of endome- 
tritis, but more eomni*mly with the se|itic and gonorrheal forms. 

In mo8t cas<^8 rejx'ated Imeteriological examinations of t!ie dis- 
cliarge from the cervix are the only way of distinguisliing to a 
certainty the cause of the inflammatory |nx>ce8s. The results of the 
examinations are so often negative that we Eiv left with only a 
probable diagnosis founded on the history alone. 






Senile Emjomhtritts 



Senile enrlometritis is an atrophic form of endometritis occurring 
in women who have passed the menopaiLse, oecurrhig particularly 
in |XK>rly nouiished subjects. It is due to the infection of the 
atrophying nmeasa, but what causes the infection is not known. 
Pathologically the (endometrium is found thinned, the glandular 
elements are wanting, and many times the endometrium is entirely 
replacted by connective tissue. Them may be stenosis of the 
uterine cavity from adhesion of the walls, and, from the same cause, 
the retained secretions may form a senile |>yometm or liytlrometra. 
The latter is very rare. The symptoms have an insidious onset, a 
thin, purulent, often offensive and irritatm^ vaginal discharge 
binng the* chief symptom. Pruritus vulvie is common, also vulvitis. 
Sonietinjes the diseliarge is tinged with bloiHl There may lx» 
jsrymptomj* of mild sepsis if the discharges are retained, and in thia 
pelvic pains are to Ix^ exjx»eted* 



184 THE DIAOXaSLS OF ENDOMETRITIS 

The physical signs show the uterus to 1k» small (unless there is 
pyometra), and the cervix uteri is atrophied. An attempt to pass 
the sound will reveal partial or complete atresia of the uterine canal. 
If the canal is patent the discharge is seen issuing from the os. The 
disease, coming as it does after the menopause and attended as it is 
by a foul discharge, may be mistaken for carcinoma of the cervical 
canal or body of the uterus. Dilatation and curetting, with an 
examination of the tissue removed, will settle a doubt. 

ENDOCERVicrris 

Endocervicitis is a chronic inflammation of the mucosa of the 
cervical canal. It is called also cervical catarrh and cervical 
endometritis. The disease is confined to the cervix uteri, — there 
is no extension to the mucosa of the corpus uteri. This is a common 
affection. The gonorrheal form has been described under chronic 
gonorrheal endometritis. Lacerations of the cervix are a frequent 
cause. When the cervix is torn the lips become everted and are 
subjected to trauma from (1) pressure on the posterior wall of the 
vagina by scybalous masses in the rectum resting on the unyielding 
sacrum, or (2) from excessive coitus. x4nother conmion cause of 
endocervicitis are polypi originating either in the mucosa of the 
cervix or corpus. 

The cervical tissuc^s in endometritis become hypertrophied, the 
mucosa is eroded, and cystic degeneration develops. Infection is 
difficult to dislodge as the bacteria occupy the glandular crypts. 

Erosions of thk Cervix Uteri 

Characteristics. — Erosions of the cervix uteri are characterized 
by a dark red or purplish color of the tissues immediately around 
the extenial os uteri. Having the appearance of ulceration they 
were formerly believed to be true ulcers. 

In an erosion there is no inflammatory action accompanied by 
destruction of the epithelium as in ulceration. The surface 
squamous epithelium, which normally covers the cervix, is re- 
moved, — it is eroded, — and the underlying colunmar epithelium is 
hypertrophi(Hl. 

(1) A simple erosion pr(\sents a uniformly smooth, velvety surface 



EROSIONS OF THE CT.RVIX I TERT 



isr> 



with *Hlmrply dcfhitHl rd^t's, Un luirnjscopic rxaiiiination it is 
seen to consist of a .single layer of coluiuiiar epitheliuai witli little 
or no fornmtion of new glantls, 

(2) ^4 papillamj ei^omon lias an irregular projeetion of its livi'l 
red surface and !ia.s been cailed **coek\s-corab granulatione." Here 
the microscope shows deep invaginations of the columnar epithe- 
lium to fonu glandrtj alternating with elcA^ations made up of newly 
formed connective tishue anil rounii eells. The glands secrete a 
vi.seid mucus. 

(3) A follicular erosion is one in wliieh retention cysts— the so- 



Fio. ^. — Eroflion of the Cervix with Liice rations. 
(H. Macuaughtoa-Jones.) 

called Nabothian follicles — are present in considerable number. 
These eyst8 are fornM^l hy the occlusion of tfie newly formed glands 
n-ferrtH] to in the destTi[>tinri of the papillary rnision. They are 
fillc<l with inspijssated mucus and vary in numbcT. There may Ix^ 
liidf a dozen, or the cer\ix may he fairly riddled with them. In 
dxe they var}' from a BJi shot to an English walnut in extreme 
0218^*8. They are usually nnt larger than a p<m. To the examining 
finger the retention c\'i?t feels like a shot; to the eye it api)ears as 
a little mundeil elevation of a bluish-white or yellow color 

Diagnosis. — Leucorrhea is the constant spiiptom of entlocervi- 
citii*- The diagnosis is made by digital and speculum examinations. 
The finger detects lacerations, the soft velvety surface of the 




186 THE DIAGNOSIS OF ENDOMETRITIS 

erosion, the stringy plug of mucus in the as, shot-like retention 
cysts, and tenderness of the tissues of the cerv^ix. The speculum 
shows the scars of the lacerations and thus their extent, the dull 
red roughened surface of the erosion, the plug of nmcus in the as, 
l)olypi, and retention cysts, if they exist. The fact that erosions 
are found in the virgin and even in the infant (see Chapter XXVIII., 
page 563) must be borne in mind. The determining factor in 
the causation of this condition seisms to be the exposure of the 
columnar epithelium with which the canal of the cervix is lined 
to the conditions which obtain in the vagina where the mucous 
membrane is paved with squamous epithelium. 

Differential Diagnosis. — The differential diagnosis concerns itst^lf 
with the exclusion of ulceration due to (1) an ill-fittuig pessary, 
(2) to tuberculosis; (3) to chancre or chancroid, and (4) to 
carcinoma. All forms of true ulceration are rare, — erosions ai-e 
common. 

(1) Ulceration from an Ill-fitting Pessary, — If an ill-fitting jx^ssaiy 
has l)Lvn removed and the ulceration does not promptly h(»al under 
approjmate treatment a piece of tissue should be excised under 
cocaine anesthesia and examined microscopically. 

(2) Tuberculoids Ulcer, — Evidences of tuberculosis elsewhere in 
the body, a history of tulx^rulosis, and microscopic examination 
of the discharge and a piece of excised tissue, will establish the 
diagnosis. 

(3) (a) Cliancrc. — The history is an important consideration. 
A definite period of incubation of th(» disease is present an<l the 
symi)tomat()l()gy and signs are those of syphilis. Chancre is 
s(»ldom i>{'cn in the initial stage, i.e., Ix^fore ulceration. When 
ulcerated it is a single ulcer. The ulcer heals under antisyphilitic 
treatment. The differentiation of the Spirocha^ta pallida in a 
piece of tissue removed for microscopic examination makes the 
diagnosis certain. 

(h) Chancroid. — Here one finds multiple ulcers appearing soon 
aftc^r a suspicious intcTcourse and no symptoms of syphilis. 

(4) Carcinomatous Ulcerations. — Th(\se are generally attendetl 
by much thickc^ning of the surrounding tissues and bletnling. 
A piecc^ of tissue should be excised and sent to the pathologist for 
microscopic examniation. 



niAFFKR XII 

THK DlAliNOSlS OF PELVIC INFLAMMATION 
(Pehnc Peritonitis and Pelvi4: Cell ul it in) 



187 



Routes of 



Dcfi nil ions, pelvic j>eritoniiis and pelvic celhilitii*, p. 
infeetion in jn^h io inilfimmatioii, p. 187. 

Pelvic j>eritoiiiliH, p. 188: Analomy, p. 188. Ktiology, p. 1HJ>. Viirletiis, 
p. IfM); Acute f>elvic fierih>nitis, p. IflO. Chronic fielvie peritonitis, [>. 11)1: 
Tiiljercnlous pcrJtaniti.H, p. IIH. 

Peh-ic n'llulitis, p. \\H: Anatomy, p. UH. litiology ami piitliolcigy, ]>. Ul'i; 
Pelvic ahstx-ss. p. lM:i. Sympltuns, ji. U):?. Dia^iosis, p. 104. 

Tabic of flitferentinl cliagiiosiH of j>elvic rnflantination, p. 1!1*k 

Definition. — The tonii prlvir inflanmiation rfgnifies broadly 
inHaniniatory at'tion situated in any of the ^nicturos occupying 
tlu* |K*Ivds. It will !>(' usnl in this rhai)trr tn nican inflaniniatinn 
in the [Jtrntoneuiu which eovei's tlu* pidvic orgau,'^, and in the under- 
Ijing cellular connective ti.HHue of the p*^m. 

The inflannnatnry prDcess wlieti eonfinrd to the pf^lvie peritoiieum 
con.stituti'S a jx*Ivie jjiTitonilis, and when in the ja^lvie cellular 
tM8ue a pelvic cellulitis. 

Peine PeritmiitiH, — This is a ver>^ common affection and acconi- 

.pduiici^ in flainniatory affections of the ovaries and tulx^s, as well as 

.inflainmattoii of the jwritunrum of the cntin' pf^i'itonral (*avity. 

The inflammation extends to i\w ceilular tissue from propintiuity 

and theit'fore the two processes are often coniltineth 

Pelvic Cellidiiis, — This, on the other han<l, is a rare affliction 
following lalx)r or alKJrtion and exhihits less tendency to extend to 
the peritoneum and to the overlying structures. It is often ini* 
I>otvsil>|i^ to different iat<' Mween the two varirtii*s cjf p<*Ivir iriflain- 
matjon, esjx'eially in the Iat<*r stages. An attempt will Ix* made 
to dcHcrilx* lK>th forms, Ix-ginning with the more iniijortant: first, 
flaying scmK thing of the routes of infection and the character of 
the structures involved. 

Routes of Infection in Pelvic Inflammation. —In feetion may rearh 
the pc*Mc peritoneum and cellular ti.ssui* (1) from tfsf* tjutsidr, 
tlirotigh \}w hinu^n of the vagina, uterus, ami tubc?s, or (2) from the 
L1<hh1 rurniit and tl»e lymphatics. 

187 



188 THE DIAGNaSLS OF PELVIC INFLAMMATION 

1. It is possible for infection to travel through the vagina, uterus, 
and tubes without leaving traces Ix^hind it. Often, at the time the 
patient first conies under obsei-vation, the inflammatory processes 
in these structures have bumcKl themselves out. 

2. The blood or lymph vessels may bring infection to the pelvis 
from distant organs, though this is rare. Generally the infective 
microorganism is near at hand either in the uterus, tubes, bladder, 
or rectum, rarely in an infected ovarian cyst, a suppurating appen- 
dix vcrmiformis, or the large or the small intestine. 

Occasionally infection comes to the pelvis in a psoas abscess or 
other abscess of distant origin, such as an abscess about the sacro- 
iliac or hip joints. The following bacteria have been found in 
cases of j>elvic inflammation, generally in mixed culture, and they 
may be classed as causative of the inflammation: — 

Gonococcus. 

Colon bacillus. 

Streptococcus pyogenes. 

Stai)hylococcus pyogenes albus, aureus, and citreus. 

Tubercle bacillus. 

Diphtheria bacillus. 

Typhoid bacillus. 

Pneumococcus. 

Actinomyces. 

PELVIC PERITONITIS 

Anatomy 

The pelvic peritoneum covers the concave surface of the floor 
of the pelvis. Beginning on the anterior wall of the abdomen 
behind the pubes and passing dowTiward and backward, it covers 
first the post(Tior surface of the bladder. In this situation it is 
loosely adh(4-ent and has more or less cellular tissue under it. 
From the bladder it reaches the uterus just below the level of the 
internal os and tiienct* rises over the anterior aspect of the body of 
the uterus. This low(\st i)ortion forms the so-called vesico-uterine 
pouch. Passing ov(»r the fundus of the uterus, where it is closely 
adherent, the peritoneum is continued on the posterior surface 
of the body of the uterus to a point a little below the level of the 
internal os where it leaves the uterus to dip down deep in the pelvis 



PELV IC PER ITOXIT LS 



189 



to tonn the cul-fle-sac nf Douglas. It.s k»wo8t fioint in ihv ouI-dc*-8uc 
varies, but averages half an inch or so Ix^low the attachment of the 
vagina to the cervix. Rising from thr* nil-dt'-sae of Douglas, the 
^peritoneum roaches first ttip anterior [»art of tlic middle portion of 
the rectum. Higher uj) it reaches the m\vf^ of this vigscu^s and still 
higher the posterior portion of the first part of the rectum. At 



L 



/,: 



Fio. 70. — Reflection* of the Folds of the Peritoneum 
(UotltHl Lines). 

sides of the uterus the folds of the peritoneum fomi the broad 
aeut^s. Aljove they vayvv the Fallopian tubes and the posterior 
of the ovaries. 

Etiology 

Pelvic peritonitis, the more common of the two sorts of pi^vic 
tnflamfnation, is almost always secondary to salpingitis. It may 
follow the escape of pus or even menstrual blotxl or injected fluid 
the ostiimi abdominale of the Fallopian tube*, or it may follow 
tic metritis, cystitis, [»roc»titi.s, jH^rforntion of thr* uteruB, appendi- 
citis, or pmoF alif^ess. 

The ^onococcus and strtptococcus are, lis far as we know, the 
bacteria mosft frecjuently tlie cause of pelvic i>eritonitis. 



190 THE DIAGNOSIS OF PELVIC INFLAMMATION 

Varieties 

The disease is acute or ehronie. 

Acute Pelvic Peritonitis. — ^This is manifest<^d by slmrp pains in 
the lower abdomen and pelvis, rigidity of the abdominal nmscles, 
tenderness to examination both of the alxlomen and the vagina, 
fever, rapid pulse, nausea, vomiting, constipation, and nervous 
depression. 

The greater the tendency of the peritonitis to become a general 
peritonitis, the more pronounced are the symptoms. If the resist- 
ing power of the individual is great, i.e., a high opsonin index is 
present, and the virulence of the inf(»cting bacteria little, or the 
dose small, the inflammation may sulxside, leaving behind it ad- 
hesions between the opposing folds of pcTitoneum. Thus the tub(*s 
become glued in the cul-dc^sac frecjuently, and coils of intestine? 
are fast(»ned to the tutes. In the sc^venT grades of inflammation 
the omentimi helps to wall off the process from the general cavity 
of the peritoneum. It appHes itself to an inflamed tube in an 
ahnost intelHgent manncT. If r(\solution does not occur because 
of the great virulence of the infective material or lessened resistance 
of the patient, a chronic pelvic peritonitis, or a pelvic abscess, 
results. A\'ithout treatment such a pelvic abscess most commonly 
opens into the rcK'tum, although it may find exit into the bladder or 
through the abdominal wall. It very rarely opens into the uterus 
or vagina. 

The diagnosis is estabHslird by the presence of the symptoms 
above noted and by the pliysical signs, which are: — on' bimanual 
examination the vagina is hot, dc^noting increased body tempera- 
ture; the uterus is fixed and there is a sense of resistance in the 
tissues occui)ying tho pelvis, a board-like f(*eling. This induration 
of the i)elvic tissues, eouphnl with the rigidity of the abdominal 
walls and great tendern(\^s to light pn^ssure, make it impossible to 
map out th(! contents of thc^ i)elvis with exactness. Atumormas.s, 
if pres(*nt, is high up in the pelvis. The uterus may or may not be 
misplaced according to the situation of the greatest amount of 
(^xudate. If then^ is an al)sc(\'<s pr(\*^ent a point of softening is to 
be s(^arched for. Abscess, h()W(»v(M*, is generally rare and, if present, 
occurs in the later stages of pelvic pcM'itonitis. Speculum examina- 
tion aids little in the diagnosis of this affection. The uterine 



CHRONIC PELVIC PERITONITIS 



101 



lisctiarges an? climinLshptl at the on.^t antl increased in the lattT 
^es. The detection of a vagiaitis may show tlie origin of a pelvic 
IM'ritoiiitis and the isnlntitm of an infective bacterium nifiv .sliow its 
nature. So also, examination of the rectinii or l>laddcr, should 
symptoms point the way, may help us to find the route taken by 
the inftrting agent in reaching the pel%ic peritoneum. Examina- 
tion of tlie blood generally f^hows an increase in tlie numlver of white 
cells, ahhough this is not an invariable concomitant. 

Chronic Pelvic Peritonitis, — This begins witli an acute attack, 
althctugh the syni^itoms may Ix* of inconsiderable moment, so as to 
j^escsix! the patient 3 notice. Often thi*re will l>e a history of a 
?ries of acute attacks separateil by interv^als of months or years. 
[The symptoms are fiain of a dull char-acter in the pehde region, 
kache, constipation and {minful defecation, rhsturbancc of 
Ider function, and pfjor health. l'hysi<'al examination reveals 
larger or smaller amount of exudate and limitations of the 
[liioliility of the utrrus, tulx^s, and ovaries due to adliesious. Th(\sc 
[organs are apt to fx* displac^ed a.s well as enlarged. TendcTnes;^ in 
the ehn>nie stage is not a prominent factor as in tlie acute form. 
Pchic absce^ may re^^ult in the coim?e of a chronic pelvic pCTi- 
Ltoiiitis. Tills will U^ describni more in detail under pelvic celhilitis, 
; it IS more often found in the latter affection. 
TuheradmiH Peritonitis, — Tuberculous |>eritonitis is one variety 
chronic jH'Ivic ixTitonitis. Here the disc^as**, as seen clinically, 
Ks seldom limitinj to the jx'lvi.s, Iw^ing an affair of the general peri- 
Itoneum. 

The disease t)i*ginf* in the Fallopian tuV^rss in a vast majority of 

instance^*, and is sometimes seen and diiignose<l be-fore it has 

Fi-iiehe*! the general peritoneal cavity. It is characterized by a 

^railuai onset, by fever recurring every evenirig and disappearing 

in the monijng, rapid i>ulsi% sweathtg, particularly at night, loss 

of weight, lo^s of strength^ and anorexia. As the ilisease progresses 

'there b* enlargement of tlie alxlonien ilue to the prei^ence of plastic 

exuilate or to the accumulation of Huid. Early in thr disc^asc 

.nothing characteristic can lie made out. An enlargement of a tube, 

^mith .surrounding exudate, increasing hi size w^hen examined at 

repeftttHJ intervalf^i roni>letl with a family history of tul)erculosis, 

previous tuberculosis in some other organ, and the symptoms just 

eoutuemtetl, make a prol>al)Ie iliagnosis «^tf tulx^r(^ulous pehic fjer- 



192 THE DIAGNOSIS OF PELVIC INFLABIMATION 

itonitis. Elimination of the other causes of salpingitis, such as 
gonorrhea, may be of assistance. The disease is found most often 
in virgins. In chronic pelvic peritonitis we do not expect to find 
leucocytosis, even if an abscess is present, although it may occur. 
Pelvic peritonitis leaves behind it many disabling lesions in the 
shape of adhesions and displacements. It is the cause of a large 
l)ortion of the diseases peculiar to women, and therefore should 
receive most careful attention at the hands of the physician. 



PELVIC CELLULITIS 

Anatomy 

The cellular tissue of the pelvis lies under the peritoneum. In 
it pass the blood-vessels, arteries and many large veins, and 
the lymphatics. It is most abundant in the bases of the broad 
ligaments and between the peritoneum of Douglas' pouch and the 
vagina and lower rectum. Therefore, these are the situations 
where the collulitis occurs most often. The peritoneum is pretty 
closely attached to the uterus, Fallopian tubes, and ovaries. That 
is to say, veiy little cellular connective tissue is present under the 
peritoneum in these regions. It is less closely attached to the 
bladder. 

Etiology and Pathology 

Pelvic cellulitis is a relatively rare affection. In more than 
two-thirds of the cases it is of puerperal origin, and is generally 
due to infection by the common pus-producing cocci which enter 
the pelvic celhilar tissue from the uterus. Infection may come 
from the vagina, rectum, or bladder, or from unclean instrumenta- 
tion or septic manipulation. The trauma incident to parturition 
opens the way for the entrance of bacteria. The common situa- 
tions of the inflammation have been foreshadowed in the descrip- 
tion of the situations in the pelvis where cellular tissue is most 
abundant. The lymph vessels and veins are affected first. A 
lymphangitis or a phlebitis may be limited by the plugging of a 
vessel by a thrombus, and in such a cas(» infection goes no farther. 

In pelvic c(^lluHtis the infective process extends to the tissue 
about the vessels, the cellular tissue, and we have a cellulitis. 



PELVIC CELLULITIS 



193 



Tin* infc^ctive inflaiiiniul i<)ri may go through all thrc^e of the niitial 
Htagps of inflammation, i.e., eongestinii, effusion, and supimnition, 
or only the first, or the fii*st two. Th(^ pniress^ from a patliolo*rieaI 
fK^int of view, is not iso different from that of a funmck% namely, 
infect ion conveyeil into a eonneetive-tiHsue area. 

Pelvic Abscess.— If the procet^s goes on to suppuration the pus 
U evaeuate*! in timt* spontaneously into th</ vagina or other pelvic 
viscera, often doing a g(M)d deal of ilaniiigc* before this issue is 
attaincHi. Should the ab«ce.S8 opru intn the liladder or reet\ini, 
it h unlikely to heal and the patic^nt l>(*roni(\s st»|)tie and tlies from 
Hc^ptieemia after a long illness. Tins is fretjuentiy tlie result even 
if most thorough tlrainage is made, ])ro\nded intervention has 
b(*en j>08tpon(Hl until the ai)sees.s has burrowed extensively into 
the tissues of the pelvis and the resisting ]>owers of the i)atient 
have IxM'n rf*<luenl to low limits. Early surgi<"al interv^ention 
and drainage of the abscess into the vagina result in s[HH*<ly Inal- 
ing, just as in the case of a boil, with notliing h'ft behind cx^-fpt 
iualix>sition of the utenis, tulx's, nm\ ovaries, and rarely ilishication 
of the blatlder, or strif*ture of the rectum or urethra. 

There is no tendeney to reeurn^nee and nn ehn^nie process as 
in the cas<? of p<*lvic peritonitis, wliere thc^ itiHamnuition originates 
ill the Fallopian tul>e, whiclj is !irit*d with mucous mt^mbrane. 
It is a welt-known fact that infection tendi? to lurk in mucouH 
membranes, and it does not rem?dn in the cellular tissue. Forms 
of chronic cellulitis have Ix^en d(^serilxHI, such as t lie chronic atrophic 
e4^llulitis of FrfHUid, alsc^ an edematous form. It is a <tiif'^tion, how- 
ever, whether such processes really originate in the (*(*llular tissue. 

A i^wlvir aljsi'ess may n'sult from a ru]>tun* of a pyosaliiinx into 
the cellular tissue of the broad ligainc^it or <>f th(^ retrouterine 
s|)aee. In this ca^ one would expt^et that tin hruling process 
would he more protractetl, and such is generally the case. So also 
in ^vere gi-ades of cpllulitis originating in the uttTUs, the over- 
Ijing tubes and ovaries Ix^conu* infecttnl by extension and have 
to be reckontil with in the treatment and prognosis. 



Tlie symptoms of pelvic cellulitis are (a) general, those common to 
tion»,t.c,, fever, rapid pulse, chills, prostration; and (6) local, 

13 



194 THE DIAGNOSIS OF PELVIC INFLABfMATION 

severe pain in the pehis, sensitiveness to light touch, both of the 
abdomen and the vagina, also dysuria and painful defecation. The 
local symptoms abate quickly, even if the process goes on to sup- 
puration, and most rapidly if resolution occurs. 

Diagnosis 

By conjoined manipulation there is found a tumor in the pehis 
occupying the region of the broad ligament on one side, or the 
retro-uterine space behind. The recto-abdominal touch is espe- 
cially useful in diagnosing this affection. If the mass is in the 
usual situation in the base of the broad ligament, the uterus is 
crowded to the opposite side, the tumor, wliich is hard or boggy 
to the feel, bulgi^s into the vagina. If the tumor is in the retro- 
uterin(» space the lumen of the vagina is encroached upon and the 
bladder and cervix are crowcUnl forward against the pubes and 
anterior alxlominal wall. In the acute stage there is rigidity of the 
abdominal muscles, as well as sensitiveness, so-called peritonismus. 
This soon subsides. In th(^ later stages when there is abscess for- 
mation it is difficult to find the situation of the uterus without 
the aid of a sound. There is a mass in the pehas that may occupy 
nearly the (^ntire cavity. The pus generally burrows into the 
n^tro-utoriiK^ space. Rc^ctal examination will often show the 
upper limits of the tumor; combined rectal and vaginal examina- 
tion is always of value in mai)ping out the size and form of the 
soi-t of cc^llulitis that Ix^gins in the rt^tro-uterine cellular space. 
In sonu* cases there is markcMl iMleniatous thickening in the space 
Ix^tween the u\)\)vv and middh^ portions of the vagina and the 
rectum. This is i)ali)at(^d with great exactness by one finger in 
the rectum and anotlier in the vagina. The detection of fluctua- 
tion in a pelvic abscess in not easy bi^ause thick walls of lymph 
arc* effus(Ml and encompass a collection of pus of any considerable 
size. 

Often an effusion of blood in the jxTitoneal ca\ity, a pehic 
hematocele of sevi^ral weeks' standing, simulates a pelvic abscess. 
The hematocele sluuild have a boggy feeling, not unHke feces of 
pasty consistency, but on ac(H>unt of the wall of organized hinph 
with which it is surroundcxl and the tension of the contents of the 
sac there may Ix' no boggy feeling. The history of the begmning 



DIFFERENTIAL DUONaSiS OF PELVir INFLAMldATION 195 

of the attark^ if obtainable, will throw light on the diagnosis, 
hematocele Ixiiig ushered in by severe pain and rectal tenenmus, 
and with prostration but no fever. Pelvic cellulitis always begins 
mih fe\Tr. 

The sequelae of pelvic cellulitis siw not so serious as those of 
{)ehnc peritonitis. Neglectcil cases may leave crippling trace^i 
beiausc of the involvement of ovaries?, tubes, rectum, ureter, or 
bladder. Cas4\s which end in sfM»e<Iy n^snlution, eitlier sijon- 
taneously or Ix^aiLse of prompt surgical interference, often leave 
no other traces than a cicatrix, or a small area of induration in 
the vagina. 



DIFFERENTIAL DIAGNOSIS OF PELVIC INFLAMMATION 

The following table of the diQcrential diagnosis of jx^vic inflam- 
mation ha*^ Ix^en modilinl from that in E, C\ DutUey's '* Text- 
book of Gynecology *' : 



Pdme PcriUmitis. 

A. ExxuiaUi surruunds uterus and ta 
wpi to hn high in pelvis, 

Fi. Utcnw fixwl wherever it happ^iiii 

be, 

C. Pain seven! and paroxysmal in 
mrute staip?, 

Li. Tendency to mippuration not 
pULfked. 

K- Frvciueniiy resuJtA in general 
pv»ntonituf> 

F. Constitutioiuil •yniptotnji more 
^tpd. Apt to be QHUaea and vomit* 



Pdtdc CeUidiHa. 

A. Tumor usually at one side of 
uteruA and low in pelvis. 

B. t'teru« displaced laterally, not 
neoeswarily fixed, 

C. Pain leas severe and more con- 
tin uoals. 

D. Tendency to suppuration marked. 

E. Seldom results in general per- 
i torn tin, 

F. Ckjiistitutfonal sjTnptoms less 
severe. No nausea and vomiting. 



P^vic PeriUmitu in Dmt(tUu' Cul^ie-mc 

Tumor mtiAs han a »\u\r\y outline 
m n'latively liiich in |iel\i^, 

B. Uterus is disiilaeed fon^^ani 




Hftro^uijeHne CeUidttis, 

A. Tumor mass of indefinite outline 
is situatwl in the apace between rectum, 
vagina, and uterus in pehic floor and 
ia flattene^i in form, 

B, Cer\ix uteri alone bent for^anl 
or to the aide, not the body and fundus. 



196 



THE DIAGNOSIS OF PELVIC INFLAMMATION 



Pyoaalpinx. 



Pelvic CeUtUUia. 



A. Mass on one or both sides of A. Mass on one side of uterus only 
uterus and back of it, not bulging into and low in the pelvis, bulging into the 
the vagina. vagina. 

B. Mass of shaq? outline and sausage- B. A diffuse swelling, 
shaped. 

C. Mass partly movable. C. Mass fixed. 



Chronic Pelvic Hematocele. 

A. History of tubal pregnancy with 
symptoms of sudden internal hemor- 
rhage. May be rej)eated light attacks. 

B. No chill or fever. 

C. Relatively rapid inci-ease in size 
of tumor. 

D. Tumor doughy and elastic. 

ApperuHciiis with Abscess. 

A. Onset with severe symptoms and 
nausea and vomiting. 

B. Tenderness over appendix region. 

C. Exudate high up in pelvis. 
Reached by vaginal or rectal examina- 
tion only with difficulty. 



Psoas Abscess. 

A. History and symptoms of tuber- 
culosis. 

B. Exndences of Pott's disease. 

C. No history of acute onset. 

I). Limitation of motion and pain in 
thigh. 

Subserous Myonm. 

A. No history of infection. 

B. No history of acute onset. 

C. Contour of the tumor rounde<l, 
sharply defined, and tumor intimately 
connected with the uterus. 



Pelvic CellulUis. 

A. History of infection. 

B. Chills and fever. 

C. Slow development of tumor. 

D. Tumor hard until suppuration. 

Peine CellulUis {Right Side). 

A. Onset with less severe symptoms; 
no nausea and vomiting. 

B. No tenderness over appendix 
region. 

C. Exudate low in pelvis in base of 
broad ligament or in retro-uterine space. 
Easily palpated through vagina an<l 
rectum. 

Pelvic CellulUis. 

A. History of non-tuberculous in- 
fection. 

B. No evidences of Pott's disease. 

C. History of acute onset. 

I). No limitation of motion or pain 
in thigh. 

Pelvic CellulUis. 

A. History of infection. 

B. History of acute onset. 

C. Tumor of indefinite outline and 
not so intimately connected with the 
uterus. 



niAITER XIII 

THE niAGNOSlS OF CONGENITAL ANOMALIES OF THE 

ITEFU'S, LACERATION OF THE CERVIX UTERI, AND 

DI8EA.SES OF THE UTERINE LIGAMENTS 

Diagnosis of congenital nnomafie^ of the uterus, p. lf>7 : L Anomaliea dui' 
lo arrest of develojjiiienl, [i. 1I*H : Absence of llie titcrus, p. 198; Kydiinenturv 
utrrus, (>, H>8; Ulerys hiparlitus, p. "iOi); Itcrits iJi<]elpliys» fi. "siOO; Ulerus 
bicorriis, p. 'HM); rieru!* «i<.*ptys. p. "200; tlcnis unicurnis, p. '^00: Dingnosin, 
p. ^l; IHHercntial «iiii^iiosi3. p. ^Oi. IL Atitvrujilies due ti) arrest of grnwlh, 
p, ^(Hi Itifarilik* ulenis, p. ^0;i; ('aiigenitul atrophy* p. *£0:i; Pueqjeral 
alrnphy, p. tO'A: Non-puerperal iilropliy, p. 'iOH, 

Diagnosis of laceration of the cervix uteri, p. 204: Atiatotny, p. 50 >, 
Etiology, p. 204. Mechanism and pathology, p. 205. Results of laceration, 
p. 200: Subinvolution, p. *207; Diagnosis of laceration, p. 208: Recent 
lacrrations, p, 208; Old lactTations, p. 20!>, Ditferciitial diagnosis, p. 210. 

Diagnosis of the discast^^ of the uterine hgaments, p. 21(»: The Unmil 

ligaroents, p. 2t 1 : Parovarian cysts, p, 21 1 ; Varia>eele of the hroa*I lif^arnent, 

p. 212. The round ligaments, yi. 212: Tumors, p. 212; Hvdnx-ele of the 

nuiaJ of Nuek, p. 2K?, Tlie ulero-sacral ligaments, p. 21J. The ulero- 

I (rvartan Jigaments, p, 21 L 



Certain pointi^in tlie anatonjy and mechanics of the ytt^riK^have 
been considen^d in Chapter V,, page 44, an<l others will Iw 
dpifcribed in Chapter XI\\, on the diagnosis of nial|jo:^itions of tlu* 
uteru8» page^ 222-224, Thr «_»ndon natrium hixs U^vn deserilx-d in 
Chapter XL on Endonx^tritis, page 15(1 In tht^ presinit chapter we 
will take tip the arrt'«t**^ of dr'velopnient, laeeratioius of the errvix, 
and diseases of the uterine ligaments. 



DIAGNOSIS OF CONGENITAL ANOMALIES OF THE UTERUS 

Tlie litems, which in the virgin measures thnn- inches in lengtli, 
two inches in breadtli at the fundus, and nearly an inch in thiekneKs, 
b* develojied from the coalescence of the two MuUerian duet,^ in 
^the embryo. Thif? eoaleseenee takes place from thv eighth to 
rthe twelfth weeks of fetal life. ITie devt^lopment should Ik^ com- 
plete, with the septum I>etwei*n the two ducts al>sorlied and the 




Absence of the Utems. — Compkto abstmec of the uterus, t\e., 
thorn cases in which there i.s present not even a knob of tissue at 
the u|)per end of the vagina to represent a uterus, is an affair only 
of non-\dable fetal monstrosities or pseud o-liermaphroditos. 

Rudimentary Utems.— Rudimentary uterus, on the other hand, 




200 CONGENITAL ANOMALIES OF THE UTERUS 

the [)hysiciaii Ix^cause of the absence of menstruation. The case 
of a niarrieci woman reported by me, — ** Congenital Absence of 
Uterus and V^agina '' (Atner. Jour, of Med. Sci.y March, 1897), 
came under obsc^rvation because of the absence of a vagma. 

The diagnosis is made by recto-alxlominal examination with the 
patient under an anesthetic, — also by examination with a large 
sound in the bladder and the finger in the rectum. An absolute 
diagnosis can be made only by an abdominal section or by a post- 
mortem examination. 

Uterus Bipartitus. — Uterus bipartitus consists of a poorly de- 
veloped cervix continuous with two rudimentary united comua 
which are usually solid cords, but may be provided with pervious 
canals as in the figure. The ovaries are generally present in an 
undeveloped state. Here only the lower part of Miiller's ducts 
have succeeded in coalescing to form a cervix, failing to unite in 
their upper portions. 

Uterus Didelphys. — This is rare. It consists of two separate 
uteri, each with one horn, and two separate vagina). Sometimes 
the lowcT extremity of one vagina is occluded at some point above 
the vulva and may contain retained secretions. (Sec Congenital 
atresia of the vagina, Chapter XX., page 357.) 

Uterus Bicomis. — Uterus bicornis is a relatively conmion condi- 
tion. In it Miiller's ducts have miited to form a cervix with two 
canals and two ora, but are unmiited above, so that there are two 
long comua representing a uterine body. Sometimes the union 
has progressed to a i)oint a little higher up in the cervix and we 
have one* (wternal os and one ccTvical canal below, and two cer- 
vical canals alx)V(^, or the condition known as Uterus bicomis uni- 
collis. (See Fig. 78.) 

Uterus Septus. — Uterus septus is the coalescence of the ducts 
to form a uterus which appeal's to be normal externally but within, 
its cavity is divided longitudinally into two cavities by a persist- 
ence of th(» septum. 

Uterus Unicornis. — Uterus unicornis results from the develop- 
ment of only one cornu, the other being entirely absent or rudi- 
mentary. Th(^ corn^sponding Fallopian tube is generally absent. 
If secretions accumulate in the rudimentary cornu, there being no 
outlet, a distended sac will be fornKnl; but fortunately this is a 
rare happening. Pregnancy may occur in a rudimentary horn, 



ANOMALIES DPE T(* ARREST OF DEVELOPMENT 



201 



al:^ in uterus tliilclpliys, ninl, t>f ^^rnirsc, in utmis st^ptuH. (See 
Chaptrr XXIL, pagi >433.) 

Diagnosis of Uterine Anomalies Due to Arrest of Development.^ 

Tlip (liagnohiri uf uterine anoiiialie.^ tlue to arre>t of (trvel(j[jnient 
rt^^s on the gjTnptoniHi in the rare cases where aeeurnulation of 
secretiom* forms a sac that presi^s on the Matltler or rertuni, tjr 
causes cramps; or cases in which menstruation do(^s not occur at 
tlie normal age. As I'egartis thr lattrr it sliould Ix' renienibered 
that menstrual blood may How from one half of a uterus while it is 
rolit^cting in the other half. Alxirtion anrl prt^niature labor are 
more frequent in the case of doul>lr uterus, and the pres<*nce of a 
!S(i>tu?n makes delivery difficult a!id involutirm s|(nv*T, A decidua 



^^wf fftfluU^ 









f/ prn^ffftj'*, 



Fio. 7S- — Btoomuie Uterus, One Ext*?nuU Os, Two Uterine Cavities. Removed 
from Single Woman 3 J Ycurs okl, Jan. 27, I9(J3, fur lic^lx-Ilioua Dysmenorrhea, 

forms in the empty half of a septate pregnant uterus or in a rucli- 
jliientary horn just a^ it fonns in the uterus in the cas<;* of tubal 
pregnancy. 

By examination the presi^nce uf two vaccinal canals is a definite 
indication of a double uterus. If the vagina is single the two ora 
of a iliilelphys titcrus n»ay Ix* palpated by the examining finder 
anil may U* s<*( n through the specuhnn. Two uterine horns, or a 
iliviiU*<i fundus, may be fi»lt by bimanual examination if the 
conditions are exceptionally favorable, that is, a thin and lax 
aljdortiinal wall and alis</nce <»f much fat. If the uterus feels 
nonnal to the birnamial palpation except for the presence of two 
ora in the cervix, two sounds are pa^ssed i^imuhaneously, one into 
LCAch 09B, and an attempt umdc to make them meet iji the uterus. 



202 CONGENITAL ANOMALIES OF THE ITTERUS 

If they do not meet, tlu^ ease is one of uterus septus. If the se{>- 
tuni (lo(»s not reach to tli(» external os the diagnosis is more diffi- 
cult, and in this case the Iow(T edge of the septum may possibly 
be felt with the tip of the sound. If the bimanual touch shows 
that there is a depression in the fundus we have to do with a case 
of uterus didelphys or uterus bicornis, the latter being much more 
freciuent. The halves of a uterus bicornis are commonly closely 
adherent well above the level of th(» internal os and can not be 
moved independently, wluTcas in the case of uterus didelphys 
the two halves are \\v\l s(»parated and can be so moved. They 
may lie even at some distance from each other, and the point of 
separation may be felt by rectal palpation, and if the conditions 
for pa)i)ation are favorable, an ovary attached to each horn may be 
palpated. 

The diagnosis of the onc^horned uterus is not easy. The fundus 
is found to one side of the p(*lvis, it is tapering, and only one ovar>' 
can b(^ made out. IlematouK^tra or pyometra may be present, 
and are to be diagnoscnl as swellings occupying a iX)rtion of the 
uterus. The diagnosis is difficult and is seldom made exactly 
without ojH^ning the alKlomen. 

Dififerential Diagnosis. — It is important to distinguish pregnancy 
in a detached cornu of an anomalous utems from a fibroid tumor. 
Th(» ()ccuiT(nic(^ of irregular hemorrhage from the uterus and the 
al>senr'(^ of the signs and symptoms of pregnancy, together with 
hardness and irregularity of the surface of the tumor, serv^e to 
point toward a filmnd. 

II. Anomalies Due to Akrest of Growth 

These are infantile or puerile vteimSj in which the uterus of the 
adult, remains of tlu^ type found at birth, — and congenital atrophy 
of the uterus, in which the organ, though of the type of the adult, 
is atro|)]iied as a wh()l(\ These two sorts of malformations are 
not V(My uncommon. The condition known as retroposition with 
anteflexion (sec^ i)age 2.'{1) would seem to be closely allied to the 
infantile utmis. 

Infantile Uterus. — This is a relatively conmion condition. The 
infantile uterus is narrow in projjortion to its length, has a long 
cervix and a short body, and the uterus is situated well back and 



ANOMAUES m-K TO ARREST OF GROWTH 



2m 



I 
I 
I 



high in the [x^lvis at the end of a long vagina, there being at the 
same time more or less antrfltxion. The os is a ** pinhole os" and 
the cer\ix is eonieaK Menstruation is usually abstmt in these eases, 
but the breasts, figure, hair, and vniee may Ix* ]HTf(M'tly normal; 
sexual desire is absent ami the patient is neeessarily sterile. The 
diagnosis is made by thr liimnmial recto-abdoniinal toueh and by 
pa^ng the sound. Thesitualionof the internal os, where the tij) 
of the mund or prolx* catches, is well up in the total length of the 
uterus and is elmracteristie, and the relatively large and long 
cer\ix, and short and slemk-r liody, ean be* nmde out easih'. The 
ovaries are apt to be small in tliese eases. Hrlp in tlie diagnosis 
L^ obtaint*<.l often if th<* utrrus is drawn down by a trnaeidum h*4ii 
by an assistant while the bituanua! toueh is practiced. 

Congenital Atrophy, — The congenital atrophic uterus is a rare 
condition. Here the diagnosis is made by finding a well-|vropor- 
tioneil utonis w^iich is small in all of its diameters. This anomaly 
18 a^iHociated with lack of Ixxly growth, absf^nre of |*ul>ie hair and 
iex eharaeteristies. \\v nmst sui»pose that the individual attained 
m pro[K?r growi:h of the uterus to the virgin type followcnl by atrophy. 
The condition has Iwen founrl in dwarfs and cretins and in cases of 
early tulxTculosis and chlorosis. 

Puerperal Atrophy, ^The ojjjxtsite of subinvolution is puerperal 
atrophy, superin volution. VineU^rg of New York has midcHl to 
our knowledge of lactation atrophy, (Amer, MedicfhSni'g. BiilL^ 
N. Y., 18Dri, Via., 1518,) It IS a shrinking of the uterus in size 
syinnietrieally Ix'low the virgin type, following prolonged lactation » 
And is due prolmbly to overstimulation of the uterus due to nursing. 
It is not a permanent condition, the uterus Returning to its normal 
size two or three months after nursing has bf*en discontinued. It 
would appear that a certain amount of atmphy is normal during 
the puerfMTium irrtsp^ctive of lactation, therefoi-e superinvolution 
is a distinctly patlioIf>gical state. 

Koo-puerperal Atrophy. — This oecui"s even more rarely than 
pueqieral atrophy, m chronic wasting disi^ases, as in tuberculosis, 
and in the acute infectious dis4ms«\s^ such as scarlatina. I have 
seen one case following steaming of the uterine ca\aty. Non- 
puerpiral atrrjjihy nmy or may not be jiermanent. The exact 
^uses are not known. 



204 L.\CERATrON OF THE CERVIX IT'ERI 



DIAGNOSIS OF LACERATION OF THE CERVIX UTERI 

The credit for a proixT understanding of laceration of the cervix 
uteri is due to Thomas Addis iMnmet, of New York, who publishcnl 
his first pajXT on the subject, "Surgery of the Cervix Uteri,*' in the 
American Journal of Obstetrics in Februar}', 1869. Previous to 
this the effects of lacerations were trc^atcMl under the name of 
ulcerations of the womb, coxcomb granulations, or erosions of 
various sorts. 

In a larg(» pro{X)rtion of cases the cervix is torn during labor, 
the few cases where it is injured by forcible dilatation or incision 
at the hands of the physician Ixing disregarded here, although it 
happc^ns not at all infrecjuently that the upjxT ix)rtion of the cervix 
is injured by the two-branchinl steel dilators employed in dilata- 
tion for curetting. 

Anatomy 

The normal cervix in the virgin is slightly conical and projects 
into the vagina from a half to five-eighths of an inch (1 to 1.5 centi- 
meters). The OS is round or oval in shape and about a sixteenth 
of an inch in diameter. In women who have lx)me children the 
OS is mon* of a transverse slit (see Figs. 65 and ()6) and may be 
irregular from lacerations, and the cer\ix is rounder and less conical 
than in the virgin. To th(» feel the tissues are firm, but not hard, 
and seen through the s[H»culum an* of a yellowish pink color. 
The wall of the cervical canal presents anteriorly and posteriorly 
a longitudinal colunui from which procecMl a number of oblique 
columns, giving the appearance of branches from the stem of a tree. 
This is called the uterine rtr/>r)r7'//a'. These columns become more 
indistinct after the fii*st lalx)r, but they are not obliterated. 

Etiology 

Th(» caus(»s of laceration may Ix^ enumerated as: (1) A rapid 
second stage of labor, (2) A large child and a small cervix, (3) A 
rigid c(Tvix, as in abortion, or from (Uminished elasticity of the 
tissues, (4) Instrumentation, as from th(» forceps or instruments 
used in embryotcMuy, or in dilatation, (5) Friability of the tissues of 



tilt' cervix ilui' tu {irolongrd pm^sure by llic pivyt^iitijig part, or 
tu dii?ciii5<* of the cervix. 

Mechanism and P \THf)Lm;Y 




In the virgin utei"iis the canal of the cervix at its widest part, 
I.e., midway Ijetween the (external o.s and tht* internal os, it^ ahoiU 
otR'-lifth of an inch in diameter. During delivery this must Ih: 
dilateil to the diameter of the child's head, .some four and a half 
inches. The muscular fib*Ts of the cervix become stretcheil ex- 
ceed vely and it i.s not surprising that lacerations occur, esj^efially 

if insufhcient time is j^ven 

for the dilatation. Lacera- 
tion?* may ix-cur in any di- 
rection or in HO vera! direc- 
tions, that is. they may be 
imilateral, l:>ilateral, or st la- 
bile, and anterior ori)oster- 
jor. They are most often 
lat4^^»ral Extensive tears 
which involve the cervix 
above the attachment of the 
vagina ai*e apt to result in 
iiift*ction of tlie pf*rimetric 
tUsue (cellulitis). Dining 

jin*^iancy the cervix tog(*thcr witii tlie n*st of the uteius is enlarged 
to arcommo<late the grtjwiiig fetus. Tlie rhythmical contractions of 
the uterus during the entire pregnancy reach their climax in labor 
when the major fiart of the hy|H*rtrophicrl uterine miiHcle acts as 
an expellent force, while the small finrtion of ih* uterus, tht* lowii* 
part of the cervix, acts a imssive r<Me and is dilated. This lower 
part of the ct*rvix may Ix^ likened to ttie sphincter ani muscle. 
^fttT reeeiviJig an excessive stretcliing as a pn*liminary to an oper- 
tion for hemorrhoids, or other operation on the rectum, the 
spliincter ani doe.s not recover its tone and is unable to contract 
for forty-eight hours, moiv or less — in fact it has Ix^^n stretch**d for 
thif^ ver>* purI)os(^ So in the ca*-^* of the lowtT cervix after laUir. 
It is ft flabby, Hoft ring tliat ha^ no f>ower of contracting. Tfidfr 
normal conditions, aiul when not laceratetb it contracts to the 



Fitj. 70.- 



liilat«.Tiil T.anTations of lh*j Cir- 
vix with Krosbns. 



L.4CE1L\T10N OF THE CERVIX UTERI 



dinietirioiis of a paroui^^ normal cervix in the eourse of a few days. 
When torn the lijjg are turned out into the \-agina W the weight 
of the large utcni:^ above and the contracting power of the cervix 
is thui? loe^t. (See Fig. 82.) The intracemral tissues are evert*H^I 
into the vagina, the uterine circulation \^ interfered with» the tissues 
become engorged and renuun swollen— therefore there is no longer 
room for them within the uterine canal Infection of the roUed-out 
nmco^ add.s to the trouble and erosions, endometritis and cystic 
degeneration result, with ultimate thickening of the torn lips from 
subinvolution. Becaui?e of the downwartl excursion of the hca\y 

uterus the cervix projects 
relatively farther into the 
vaidna and the attachment*? 
of the latter organ to the 
cervix apjx^ar to Ix? higher 
up on the uterus^ although 
in reality they are not, and 
thus the torn cervix sterns 
to be larger than it is. Sub- 
involution, or chronic rae- 
t ritis, keeps the uterus heavy 
and in this manner accent- 
uates the eversion. Lacer- 
ations of not great extent 
unite readily in the abst^nce of infection. If j>el\ic inflanunation 
is present lacerations are apt not to heal bo soon, if at all, and 
extensive lacerations may involve the vagina and even the bladder 
or rectum, leaving fistulfle Ix'hind them. It often happens tliat 
the laceration is in the canal of the cer\^ix and that the external 
OS is little, if at all, involved. 



Via, 80. — 8t<j|latc Lacenitioiifi of the G*rvix. 



Resulib of Laceration 

The imnierliatc results of laceration of the cervix are hemorrhage* 
or the produclioM of a fistula. The later result?^ are endome- 
tritis, sul)invohition of thr nteru?^, cystic degeni'ration and ero- 
sion of the cervix {^h- Clmi>tor XL on endometritis, page 184), 
thus furnishing a favorable soil for the growth of cancer, cellulitis 




RESULTS OF LACERATION 



207 



I 

I 

I 



I 
I 



Thi'8c wt^rt^ ill the piT-aseptic 



(8DC Chapter XII. on pelvic inflammation, page 192), cicatricial 
stenosis of the ut<?rine canal, and a tendency to bterility ami 
alx>rtion. As regard.s the last, Dr, Emract\s tables ('*Prinfiple8 
and Practice of GTOecologj^/' 3rd etUtion, pages 447, 448) show 
that following lacerations of the cemx 71.34 [jer cent of his 164 
cases were sterile, and of the 47 who liecame pregnant, 51 per 
cent alx^rted one or moj^e times. 
days and infection m a K^i^uenee 
to injury was undoubtedly more 
frequent than now\ 

Endometritis is* eontjidercd in 
Chapter XI., jHige 165* 

Subinvolution-— Thii< may be il*^ 
.fined as a failure of tlie physio 
'logical hy|K^rtro|>hy of pregnancy 
to mibftide after lab(ir. It is due 
not only to laceration of the cervix 
but to ma!t)osiiion of the uteru:s 
from weakening of the uterine 
ligaments and too long a stay in 
betl, with general debility follow- 
ing confinement, ^Vfter the early stages of snbinvohition infec- 
tion plays a r61e in mosrt ca^es and then* is present an interstitial 
metritis, formerly called areolar hyperi^lama. In this diseas** th(* 
conntxrtive-tissue elementn in the uterine wall are increased and 
the muscular elements flirninished In the acute stages thert^ is a 
nJimd-eelled infiltration; the utenjs is large and feels softer. In 
tlie lat^T stages the uterus is large but the tissues are iniluratecL 
Tins ifi the time when the c«mneetiv^e-tissue elements predominate 
and a pathological involution takes place. The lymph and blood 
vessels are diminished in sizr*, ci-owibnl out by the conncirtive tissue; 
the muscle atrophies and the uterine tissues iK'Conie jiale and in- 
durate<L 8uch a state of affairs i? found in uteri which have 
been many years the seat of chronic metritis, not in recent eases, 
«>., generally not lx*fore four or five years after the receijit of 
jur>' or misplacement. Suliin volution or chronic metritis may be^ 
plated with arterio-sclerosis of the uterine vessels in the later 
yeai^ of life. 



Feg, SL 



.*rcsccntic Lact^ratiotis of 

lh«* tVrvix. 



208 



LACERATIONS OF THE CERVIX UTERI 



Diagnosis of Lacer.\tiox 



The symptoms of laceration of the cervix are the symptoms of 
the pathological conditions resulting from this lesion. Immediate 
hemorrhage following labor calls for prompt diagnosis. The 
sjx^cific nervous symptoms, such as pain in the suboccipital region, 
headach(»s of the vertex and neuralgia, considereil by Dr. Ennnc^t 
to be due to a '* cicatricial plug^' in the angle between the lips of 
old tears of the cervix, are now generally thought by the profession 

to be due to a deterioration of the 
nervous system caused by pelvic 
dis(»a^e in general. 

The diagnosis of lacerations is not 
an easy matter, as l)ecomes evident 
when we reflect that the diagnosis was 
not made* until Emmet showeil the 
way in 1862. The results of lacera- 
tions so ol)scure the landmarks that 
at th(» time when most lacerations 
come und(T the physician's observ^a- 
tion — several years after th(»ir receipt 
— he is at a loss to determine the exact 
situation and extent of the injur)^ 
(a) Recent Lacerations. — In the ca^* 
of n^cent tears of the cervix the only 
bai-s to an exact diagnosis are the 
tunu^faction of th(» parts and the exhausted condition of tho 
{)atient. If there is excessive hemorrhage following delivery the 
diagnosis must \}i^ made* at once. In oth(M' cases it may be made 
in a few hours or days, (l(^pending on the patient's condition. The 
woman should Ix' in the dorsal position on a table in a gooil 
light. Tlie perin(»um being n^tracted by a large Sims speculum 
in the hands of an assistant, tlu* cervix is seized with a double 
t(*naculum and drawn down and search is made for solution in 
continuity in the circles of the enlarged os. Tears can be repaired 
at tliis tine by suturing. Some operators prefer to do this in 
an intenn(*diat(» tini(^, l.c.y four or five days after labor, {)erhai>s 
scraping the edges of the tear with sterile gauze before uniting 




Fio. 82. — Diagram Showing 
Bilateral Laceration of the Cer- 
vix with Eversion of the Lips. 



DIAGNOSIS OF LACERATION 



200 



them. The injorie:^ must tx^ followed caix^fully to their limits, 
whether they be confin(Hi to the ce.»r\ix, or if they extend to the 
vagina, or even to the rertum or the bladder 

(6) Old Lacerations. — If every woman were submitted to a 
careful uterine examination after chilil-bearing^ and injuries of the 
cervix, a.s well w^ thos4/ of th(* prhnt' H(»or, ffiuiid and n*]uiir('d, there 
would be eomparatively little for th(^ gviieeoioj^ist to do. It hap- 
pens, liowever, that most of tlie laet-rations of the cervix come 
under the physician's notice for the 
first time some years aftrT their tv- 
reipt. At tliis time the dia^^nosis is 
difficult lxM*aui^» of enlargement and 
distortion of the cervix, ev(*rsion of 
the l\\>^f and cystic d«*generation of 
the Nabothian folliclej^ and erofsion. 
The trame<l vaginal touch after a littlr /T^ ; .^^1 '5^ 
practice detects all of tliese features 
even to the erosion. For inspection 
the Sims position is be^t. Search first 
for the arbor vitre and thus lieter- 
mine the situation of the cervical 
eanah The pa.s,sage of the sound 
helps to define the situation of this 
CAnal, but the physician musi. be otl Fig. S3.— Uuilateral Lnopi-n- 
hbi guard not to Ix^ misled by the tions of the* Cervix, Pro<luc-rng 
malpositions of tlie uterus fou'nd in Obliquity of the Lon^ Avis of Ihe 
* . litems. (Mter Emmet.) To© 

ca«es of umlateral tear as pomted Hc.jupiieation of the Vagina is 
out by Emrnet. (Se<* Fig. 83,) In showTiatW. 
ihU event the sound {lasscnl to the 

conm opjK^tite to the fM*at of tljc laceration may appear to Yx^ in 
the canal (s(^e figured, but Ixn-ause of the tilting of the fundus 
lowanl the laceration the stnmd occupies the laceration and not 
the nonnal eemcal canal. Here a seiirch for the arbor vitie will 
help to set us right and tin* Imnanual touch will also assi:^. 
Putting the patient in the knee-chest pi^sitioti, thus jxTmitting 
the utertLs to fall towarti \hv afxloTTn»n high in the pelvis, straightens 
its axis and also pulls out tlu^ rtHhiplication of the vagina on the 
side where the laceration is situatr*d. In all lacerations of st*vere 
do it is well to study the conditions as seen through the speco- 
14 



210 DISEASES OF THE UTERINE LIGAMENTS 

luni when the patient is in this position, because in the dorsal 
position the weight of the uterus — usually increased in cases of 
laceration — drives this organ downward so that the intravaginal 
portion of the cervix seems to be longer, especially if the upper 
vagina has bc»come stretched. Therefore, there is present in ex- 
tensive lacerations of the cervix apparent hypertrophy and elon- 
gation of the cervix lx?yond what really exists. This reduplication 
of the vagina is showTi at X in the figure. Next, with the 
patient in the Sims position, hook a tenaculum into the crown of 
each lip of the cervix and bringing the two tenacula together, 
try to reconstruct the cervix. If there is much induration of the 
tissues this feat is difficult of accomplishment. By palpation with 
the tip of the finger or the sound, determine the situation and extent 
of cicatricial tissue in the angle of the tear, pressure on the tissue 
causing pain. With the tip of the sound a laceration within the 
canal of the cervix may be appreciatcnl, for in that situation the 
sound falls into an opening in the othen\ise smooth mucosa of 
the wall of the canal. The internal os will be found abnormally 
large should the laceration involve* this r(»gion, permitting the sound 
to be moved fnvly al)out after it has been passed through. 
When the arbor vitie has been made out the situation of the 
laceration with ref(M-onc(? to it is determined. 

DlFFKRI^XTIAL DiAGXOSIS OF LACERATIONS 

Cancer of the cervix is tin; disease most often mistaken for lacer- 
ated cervix. The (liff(M*(*ntial diagnosis is considered under cancer 
of the c(Tvix, Chapter XVI, page 272. Carcinoma is attended by 
much induration of the tissues and ulceration, also cancer bleeds 
easily and the superficial portions are friable. Endocervicitis and 
erosion is a coincidttnt condition in laceration, but may exist in 
the absence of laccM'ation. The diagnosis is based on the absence 
of the signs of laceration. Eversion of the nmcous membrane of 
the cervical canal may be pr(\sent without laceration and it is well 
to bear this fact in inind. The cervix in such cases is of nonnal 
contour and there are no evidences of laceration. 

DIAGNOSIS OF DISEASES OF THE UTERINE LIGAMENTS 

The uterine ligamcMits an^ the broad ligaments, the round liga- 
ments, the utero-sacral ligaments, and the utero-ovarian ligaments. 



THE BROAD LIGAMENTS 



111 



The I3koad Ligaments 




These become stretchecl in prolapse* of the uterus so that thoy no 
longer support that organ. Under normal conditions they have 

ough elasticity, together with the iitero-^jat'ral H<;arnents, to rr*- 

ore the uterus to its normal ^^itnation after it has been drawn 
do^-n forcibly. C'ertain tumors originate in the broad ligament.s, 
notably parovarian cysts, filiromata and Ii|iomata, also dilatation 
of the veins, varit-ocele. The solid tumoi's are extremely rare, 
Hpomata are S4*ldom ^4t*en, and fibromata only occassional ly, the lat- 
ter being not large as a rule and arising in the unstriped muscle filx^r 
bt*tween the folds of the Ugament. Sarcoma and carcinoma of the 
broad ligament are secondary to malignant disease of the uterus, 

Pafovarian Cysts.— Tlicsc* originate in Gartner's duct, Kobelt's 
tubules, or in the parovarium projxT. Small peduncuJated cysts 
may develop from one of these structures, or the cynts may 1k» 
s<*?s?ile and large. Thest* large cysts, so called, develop between the 
layers of the broad ligament and are of alow growth. They are 
seMom larger than a child's h(^a<L The cyst has no |x?dicle, the 
FaUopian tube is stretclnHl over its surface, and the cyst pushes the 
uterus to the opjxjsile side of the [K'lvis. Adhesions are rare be- 
cause the cyst is covereil by peritoneym. The wall of the cyst is 
thui, transparent, and of a gnM^nish-ycllow hue^ the contents are a 
colorless Huid of a n on- irritating characirr huving a specific 
ivity of lfK)2 to 1()08. Upon rupture the cj^i is apt not to Refill, 
in this respect iliffering from an ovarian cyst.. A parovarian cyst 
y Ik* raR^y the scat of papilloma and in this case the contents 

e o(>acjue> the walls are thick, and the (*yst is like a [mpilloniatous 
cystoma of the ovary. The diagnosis is made by vagino-abilominal 
and recto-ahlominal palpation, if necessary having the uteriLs 
ilrawn do\ni by a vuLsellum while the palpation is being practiced. 
(See Fig. 125, page 204.) The cyst is on one side of the pelvis, in 
close relation with the uterus. Its mobility is distinctly limited; 
it Is ovoid in sha|)e and has smooth walls; fluctuation is distinct, 
being felt through tlu* vault of the vagina; there is no pfnlicle, but 
a groove between the cyst and the uterus can \w distinguished. 
The differential diagnosis is considcRM^l in Chujiter X\TI, on 
ovarian tumors, page 2D7. 



212 DISEASES OF THE tTERIXE LIGAMENTS 

Varicocele of the Broad Ligament. — ^This is not a very rare disease. 
It consists of dilated veins running transversely in the upper part 
of the broad ligament and forming a tumor that may be as large as 
a small hen's egg, though generally much smaller. Varicocele is 
found more often on the left side. Perhaps this is because the left 
ovarian vein is valveless and ojx^ns into the renal vein at a right 
angle. It is possible to make a diagnosis by recto-abdominal palpa- 
tion by finding a doughy-feeling tumor in the broad Ugament, but as 
such a tumor is not tense except when the patient is in the erect 
posture, the diagnostician would be likely to miss it during the 
usual examination made \\'ith the patient in the dorsal position. 
If there are varicosities elsewhere in the body varicocele of the 
broad ligament should come into the physician's mind and he 
should examine the patient in the standing position. The char- 
acteristic symptom of varicocele of the broad ligament is a didl 
aching pain in the pelvis or back. 

The Round Ligaments 

The round ligaments var}' much in size and in length in diflF(*rent 
individuals, therefore their ability to st(*ady the uterus as guys is a 
variable quantity. The nuiscular filx^rs are situateil in the inner 
two-thirds of tlu^ ligament and sometimes th(* ligaments are nothing 
but the slenderest of cords. Fibroma, fil)romyoma, adenomyoma, 
fibromyxoma, and sarcoma of the round ligament have bt^n de- 
scrilx^d. The tumor is generally unilateral but may be bilateral. 
These tumors are thought by some writers to be associated with 
fibroids of the uterus. They may Ix^ found in any portion of the 
coui-sc of the ligament, — in the alxlominal ca\4ty, the inguinal 
canal, or in the labium majus, — and they develop slowly, but may 
be stinuilated to more rapid growth b}^ the presence of pregnancy. 
The tumors are hard and g(*nerally p(*dunculated. 

Diagnosis of Tumors of the Round Ligament. — If a tumor is situ- 
ated within the peritonc^al cavity it is felt by bimanual palpation 
in the front of th(^ p(^lvis on one side. If it is ui the inguinal canal 
or labium majus the tumor is felt from the outside in the course of 
the canal or in the lai)iuni. It must Ix* differentiated from omental 
or ovarian hernia, hydrocH'K* of the round ligament, a cyst of Bar- 
tholin's gland, or enlarged inguinal lymphatic glands. There is no 



irnpuLst* on roughing nr f^traiiung ami tlii* enlargement can nt>t l)r 
rtMlut^cil by taxis. An (»vary in the inguinal canal is very sensitive 
to pressure, antl ^^wells and is jiainfnl at the time of nienstrnation. 
A cyst of ]3artholin\^ gland will presi^nt Hue t nation, ami enlarged 
inguinal glands are g(*mTally .separate glands, i^e., tliey are multiple 
tumors and are situated to the outsi<le of the inguinal eanaK 

Hydrocele of the Round Ligament or of the Canal of Nuck* — In the* 
felas the tM'ritoneal ('u\f'ring of the round ligament prujects as a 
tubular proee^ss inhi the inguinal canal. Thi.s tube Ls called the 
Canal of Nuek and it f^otnetiiTies jx>i*sists through life. If fluid 
coll<^*ts in t!ii« canal and the alxiomiual end of tfie canal is nh!it- 
era ted there is foimd a cystic, translucent, oval tumor which may 
extend do^Tiward even into the labiuin niajus. In size the tumor 
rnay Ix* a*s large as a hazelnut or vwn attain the proportions of a 
c«x*oanut. It can not l)e pushetl up into the alxlomen, it fluctuates, 
and ha.s an impulse on coughing if situated in the inguinal canal 
In mre ca-ses the cyj^tic tumor may eoinmuni<*ate with the peri- 
toneal cavity and in this event the Huid may he forced out of it l>y 
gi'title pirst^ure. IlydnM'cle is not tender like an ovarian hernia; 
it is of gradual develof)nient and often there is ditticulty in rlistin- 
guishing a hydrocele from liernia. In the case <if encysted hydni- 
cele the ela^lic, translucent character of the tumor that can not 
be reduced with the jmtient recimilx'nt, serves to distinguish it. 
The hydrocele that connects with the [x^ritoneal cavity can not be 
difTerentlated from hernia without an 0]jeration. In the ease of an 
uiflarncfl hydrocele the dilTereutiation from a strangulated hernia 

■ \& made by the absc^nce of severe constitutional sj^niptoms, and 
I of swiptoms of intestinal oKstruction, As a matter of fact such 
ft tuinoni have generally Ix'cn operated on for t*traEigulated hernia. 

I " 

■ ol 



Thk Utero-6AcRal Ligaments 



The utc^ro-sacral ligaments contain, lx\sides connective tiasue 
anil jj€»ritoneum, as do the rounri ligaments, a certain amount 
of nuiJHcIe fibers. When tlie uterus is flra\\T) i\o\vn forcibly tijere 
ii* elasticity enough in the ligament.^ to pull the uterus back again. 
The ligaments are mucli overstretchiHl in prt^lapse of the uterus 
and art? abnormally short in R^troposition with anteflexion, in the 
latter case being almost of a cicatricial hardness. Naturally liga- 




214 DISEASES OF THE LTERINE LIGAMENTS 

mcnts of this character limit the downward or forward excursion 
of the uterus. The diagnosis of shortening is made by the bi- 
manual vagino-abdominal and recto-abdominal touch. The uterus 
is raised and at the same time the ligaments are palpated to detect 
shortening and thickening, or the uterus is brought down by trac- 
tion with a tenaculum while the rectal touch is practiced. Short- 
ened ligaments are easier to make out than lengthened ones. In 
the infant, the uterus being very high in the pelvis, the utero- 
sacral ligaments course from their origins at the second piece of 
the sacrum to their insertions on the uterus in the form of an arch 
and may be felt in this shape by rectal palpation. The operator 
should not lose the opportmiity afforded, during abdominal opera- 
tions when the cul-de-sac of Douglas is in \iew, to inspect as well 
as to palpate these ligaments from a^ve. 

The Uteroovarian Ligaments 

The following tumors have been found in these ligaments: 
fibroma, sarcoma, and carcinoma. The last two must be regarded 
as extensions of the disease from the utems; the former, fibroma, 
is very rare. These tumors can not be distinguished from ovarian 
tumors without opening the abdomen. In some cases the ovarian 
ligaments are very long, thus favoring prolapse of the ovaries. 



CHAPTER XIV 

THE DIAGNOSIS OF MALPOSITIONS OF THE UTERUS 

General considcnitions, p. ^15, 

I. MalfKxsiliofis of ihe uk*ru.s as u whole, p. 218: U Ascent, p. 218. "i. 
Descent (prolapse), jn t?18; Patlifilog\% p, €18; Mec-I»anisin. p. ^IJ); S^inp- 
toins and course, p. 'i'iii; Diiignosis, p. 'i'iC*: Oifferenliiil tiiagnasis, p. ^^K, 
S. Anleropositron, p. *2^D. 4. Latero|>osilion, p, "^^O. .5. Helro|*ositioii, 
p. itiQ: Retroposition with anteflexion, p. i'U ; Diagnosis of relroposilion 
wilh anteflexion, p. ^3^. 6, Hernia of the uterus, p. '2:1S, 

II, Abnormalities of the avis ami form of the uterus, p. ^34: 1, Retro- 
version, p, i^SI; Retroversio-flexion , p, 4:U; Diagnosis of retroversio-flexion, 
p. ^5tt, €, Anteversion, p. ^38. S. AnleflexiiMi, p. 24U. 4. Inversion, p, 
^40; Diagnosis, p. ^10; Ditferential tliagnusiji, p- 2iO, 5. Torsion, p. ^43. 



GENERAL CONSIDERATIONS 



Ix considering the subject of malpositions of the uteriLs it must 
be understood that tlisplai^ement of the ut<*rus carries with it more 
or less change in the position of other pelvic organs at the same 
time. For in.'rtance, it is manifestly inipot^sible to place the uterus 
in a condition of complete* prola|>se without altering the position 
of the tubo», ovaj'ies, bladder, and vagina. 

We shall consider in each in.stanee the dislocation of the most 
imix>rtant organ, noting the complications. The normal position 
of the uterus and thf factors which determine its situation in the 
pelvis and limit its niohilily under the varying conditions of health 
bave IxxTi describe*! in Chapter V., page 43, 

WTipn pregnant or untler condition,^ of disease the uterus is sub- 
ject to certain displacements as a whole, and its long axis may be 
tumefl or verted in one of several directions. Theoretically wc 
have to do with two distitict cla.ss«_\s of displacements. The ut-erus 
may \w likenenl to a telescope upon a stan<l in a room. The tekv 
acope may be in the mitldle of the room (the pelvis), or it may be 
plflccHl against the wall (rvtn>i>osition), or it may \)e raised (ascent), 
or If)W(^n'd (prubpsc*). Also it mny Ik: tiltrii in one of many ilirec- 

215 




21G 



MALPOSITIONS OF THE UTERUS 



tions (version) although its position as a whole with reference to 
the walls, floor, and ceiling of the room has not been changed. 

Alteration of the position of the uterus generally but not neces- 
sarily implies change in its axis, and often in its form. For in- 
stance, retroversion generally means a certain degree of retro- 
position and often retroflexion; prolapse presupposes retroversion 




Fig. 84. 



-Median Section of the Body of a Woman Who has Borne Children. 
Bladder Empty. (^Schultze.) Note Ante version of Uterus. 



in the early stages of the descent of the uterus; inversion is a form 
of prolapse. 

The l(\sion that is supposed to be the important one from a 
pathological standpoint gives the name to the displacement, al- 
though — as before stated — several lesions are involved. The 
classification here used is a practical rather than a theoretical one. 

In describing the pelvic circulation, Chapter V., page 46, it has 
been stated that the blood-v(»ssels of the uterus and broad liga- 
ments are convoluted, valveless, and capable of great distention, 
depending for their normal tone on absence of constricting influ- 



CENERAL CONSIDERATIONS 



21 : 



elm's in tht* vviiy v»f i^ns^un/ from tumoi-s or pelvic mflamnuiti»rv 
maHSf^Sy or stR*tchhig iluc to [iiaI|MisititMi nf tht* ut<4"us. 

\\ i* know liow much a nrolapso<l utn'ius is nnltKHMl in size aftt*r 
it ha.s Ix'en rcplaecil in a Jioriual [KJsition in ihv j id vis and niain- 
tairuil there for a few hoitrs vwn. Wv know thai a normal uterus^ 
clisj>lare<l dowTiwanl nierhanieally, lx*<'OTries eon^estcfL It is fair 
to iLs^smne that this is due to a straightening of the tortuous valve- 



iSMTHB* 



Fia. S4/I. — Longitudinal MfxJian Section ol a Pd vis with Ovenibtcnfied bowl- 
der (ZuckerkandL) Note Retrovermon of Ul«rua. 

]vm vein8, thujs le^^sening the resistance of their walls to an In- 
creasetl preisaiire delivere*! by the le-sj^i convoluted arteries- 
It is the view of the author that uterine nialpcjsitions have a 
direct nun^hanieal elli*i't on the pelvic cireulatiou, therefore ch&- 
plaeements of the uterus as a whole are of more importance than 
elian^i^ in the axis (version), or changes in fonn (flexions, torsions, 
or tumors) • 



218 M.\LPO?mOX.S OF THE UTERrS 



I. MALPOSITIONS OF THE UTERUS AS A WHOLE 

1. A-scont. 2. Df-scont ^prolapse). 3. Antero-position. 4. LateiD- 
jKTsition. 5. Rf/tro|X)<ition. 6. Hernia of the uterus. 

1. Ascent 

Thf* uterus is in a position of ascent in the later months of pr^- 
iiaiK-y; whon it is displaceil upward by a tumor developing from 
thf? lower part of the pelvis: when oversupported by a pessary; 
and when it lia.s been attachc^l to the abdominal wall by a ventral 
.su.sfx.'nsion or fixation ojx*ration. The diagnosis is established by 
bimanual palpation. The cer\ix uteri is far removed from the 
normal situation and in some cases can not be reached by the tip 
(ff the examiner's finger. The fundus may be palpated through 
th(? aFxlominal walls. According to our pi'esent knowledge ascent 
is not an imix)rtant displacement. The only sjmptom directly 
traceable to ascent is an irritability of the bladder, seen occa- 
sionally, and thought to be due to traction on the vesical neck. 
Prolapse, on the other hand, is extremely important as well as of 
common occurrence. 

2. Descent or Proiapse 

The extent of the dc^scent varies from a slight "falling of the 
womb" to the complete escaix* of the uterus through the vulvar 
orifice. 

W'Ikii the uterus remains within the Ixxly the displacement is 
sp(jken of as an incomplete prolapse, or descensus ut^ri; when it 
is Diitsirle the Ixxly it is known as complete prolapse, or procidentia. 
This form of (lisi)lacement is generally of slow development — a 
matter of months and years. 

An/te prolapse, duc^ to violc^nce or sudden straining when the 
uterus is ]artj:e and heavy, th(» ligaments weak, and the retentive 
|)()wer of the abdominal walls diminished — as after labor — has 
been observed as a rarity. 

Pathology. — The pathology of prolapse includes the morbid 
anatomy of all the pc^lvic organs involved. The circulation is 
obstructed by traction on the vessels and all the displaced organs 



DESCENT OR PHOLAI^E 



2ia 



I 



I 



-■%•-/ 



«ongesteil; tlir^ nerves alt^ are stretfhnti or even sundf red. 
The displaced vagina lK'eoni«*.s swollen and conge.ste<l and may bi* 
ulct"»rated; there may te hernia of the ciil-de-Hac of Douglas, and 
the reetum may oceiisjonaliy send an offshoot into the hernia; 
the bla<lder is frequently displaced anil is subjeet to catarrh; and 
the endometrium is the seat of endometritis— the uterus being, as 

nili% much conge\ste<L 

Mechanism* — To understand the meehanism of the production 
of prolapse one must consider three factors, (a) The pelvic floor, 
(b) The uterine ligaments and attachments of the uterus to sur- 
rounding structures, (c) The variar 
tions of pressure exerted by the 
abdominal contents. 

(a) Tlie pelvic fl<wr is a muscular 
and tendinous diapliragm clasing tlie 
outlet of the pelvis. Through this 
diaphragm runs the vagina trans- 
versi^ly and obliquely as a slit. In 
the erect woman the vagina is at an 
angle of about 60° with the horizon, 
tentiinating above at the neck of the 
womb, which in turn has its long 
axis placed at a right angle to the 
long axis of the vagina. 

The vagina in its course from the 
cervix to the introitus vagina? sliows an S-shaped curve when seen 
in a median longitudinal section of the body, the forw^ard bulging 
portion of the S Wng in its lower portion op|K)site the under 
edge of the s>Tnphysis pul>is* (See Fig. 85.) Tliis prominent 
portion of the vagina is made by the presence at this jioint of 
the chief muscle masst*s of the levator ani and smaller muscles 

,d fasciie making U[> the pelvic floor. It is the socalled " ]jerineal 

iy'* of the older g>^necoIogists, By reference to the diagram 
(Fig. 84) it mH be seen that this key-stone to the airh of the pelvic 
diaphragm lies about midway lx»tween the lower border of the 
^Tiiphysis and the Cixrcyx. Injury to the muscles here naturally 
d<'stro>^ the sigmoid curv^e of the vagina, opens its outlet, and 
diminishes the support to the structures lying alx)ve. The vagina, 
instead of being a flattened ribton-like canal with walls in apposi- 



FiG. 85. — S-ehuped Curve and 

IncUnation of Vagina. Not« that 
the Walk Are iu Apposition. 
(Sltene.) 




220 MALPr^srru»xs of the iteris 

tion aiitl niiiniii^ alnn»>t tniii-v«rs<'ly fnmi thi*("«»mx to the hymen, 
nnw Ui-oniis a >trait:htrr o|m-ii tuU\ Ifailiiii; ahiMi<t ilinftly ilown- 
wanl from thr crmx to th«* i;itri»itu>. 

The jK-lvic flfM»r. a<x-un!mg to Hart an«l Barlx>ur, may be cli\i<l(Hl 
up into an anti'rior anil a jK>sterior si'gment. The anterior s<^g- 
ment is a n-lalivfly movablr one, the po>-terior is relatively fixe<l. 
The ant<Tior or puhic s4-irni(.nt consists of anterior vaginal wall. 
un*thra. an<l l»hi<H«T. all attacluil l(K)s«'ly to the sjTiiphysis pubis 
by n-tn^pubic <lejK)>its of fat. The |)osterior or sacral .segment 
is niaile up of j)ost«Ti<»r va^nal wall, the muscles and fasciae of 
the |M'rineum, an«l tlu* nK-tuni. all finnly liouml to the sacrum and 
coccyx. During lal>or the anterior segment is ilrawn up: the 
|XJsterior segin<'nt is <lriven down. In the formation of prolaps* 
the anterior s<gnient. l^i^cause of the injure' of the posterior seg- 
ment, swing< downward antl l)ackwanl — the retropubic fat giving 
way with consiMpirnt dislrwation of bladder and urethra. It is 
I>lain that a tipping back of th<' uterus on its axis, so that it may 
^et into the siinie axis as the vagina, is a n-^juisite to the descent 
of that organ, and that this tipping Iwckwanl is made passible by 
injur}' of the jM)st(Tior segment of th(» jK»lvic floor and dislocation 
of the ant(Tior s<»gnient, so that the cer\ix — not stayed from lx»- 
hind and havnig no firm tissue in front of it— swings fonvanl until 
its long axis coincides with the long axis of the vagina. This 
subject will Ik' made clearer when we consider the different direc- 
tions in which under varying conditions the intra-abdominal 
pressure is applie'd to the fundus uteri. 

ih) Tlie utcrinr lijranirnt< and the attachments of the uterus to 
the surrounding stnicturcs. 

The litianicnts, descrilx-d in (1mpt(T V, page 44, consist of 
three pairs ()f ligaments projKT — the broad, the romid, and the 
utero-saeral ; and the attaehments an^ — the utero-vesical conm»c- 
tive ti.-sue, the va«iina, and the retro-uterine cellular tissue. In 
eonsi(lerin<: the causation of prolapse we must think of the woman 
Ix'ing in the erect position, l.>ecaus(» it is in this attitude that the 
great strain is hrouiiht to l)ear that causers sacro-pubic hernia. 
Hy referen^-e to tlie diatrrani (Fi<r. .S4) on page 21G it will lx» seen 
that the origins and insei-tions of all tlu» ligaments lie in nearly 
the same plane. As a matter of fact, the pubic ends of the nmnd 
ligaments are a little lower than their insertions into the horns of 



DESCENT on PROLAPSE 



221 



thr litems, then?fore the roimd ligaments can not support, the* 
uteras except in casct* of extreme prolapse. Oii the other ham I, 
the attachments of the utcrosacra! li^anient.^ to tiie jielvir wall 
near the second piece of the i^aeruni are a triiie higher than tlieir 
insertions into the uterus at the level of the internal os. They 
are nomially firm and i^trong and act a.*? true su|>[K)rts. 

The broad hiranieiits elu^ck laternl motion and liniit tfie uterine 



If 


"^"- n 




1 ^H 


V ''' ^^flM ■ ' J 


fkriHixi 


/f**^^— .-wl 




'^^ nh 


mfSiai^mjf Mielf -1 






O*^^ ilf*tfn -^0! 


^^^^^^^H^^Hy^H «A 


\ 




'^^■ji ^ '1 


f 



Fia. 86.— Right Hide of AWommaJ Wivil lliw Btx^ri Remo\t^i. 8howtrig Fun* 
I Shajicof AhKlnminal Cavity » whk'h I« Wide Above aud Narrow lie low, aUo ih^ 
ating Shelf which (ii%<.'s Partial tSupport to the V'iscern. i Alter Corning.) 

niovemfmt.H largely to fonvard antl liaekward excursions. The 
intra-ablominal prc^ssure is exertitl on the posterior a*^p(*et f>f their 
bn^ail surfaces and then^w tli<*y assisrt either in retaining the 
ulenis in ai»teversion, or. if th** axis of th<' uterus h^ lxH*n changed 
from anteversion to n*troversion, the pressure Ix'ing on their 
posterior ai?peets> they assist in ke<*ping the woinh in that position 
and in aiding prolapse. The thick basics of tlie broad ligaments 



222 MALPOSITIONS OF THE UTERUS 

intimately joinc^l with the uterus form strong connecting and 
supix)rtiiig structiux^ between the uterus and pelvic walls. Pro- 
lapse can not occur miless the attachments of the ligaments or the 
ligaments themselves arc severed or stretched. The utcro-vesical 
connective tissue, when torn asunder by labor or when weakeneil 
by the atrophy of the triangular mass of subpubic fat, promotes 
retroversion and also i)rolapse by lessening the resisting power 
of the structun^s connecting the uterus with the symphysis and 
indirectly diminishing the distance between the cervix and the 
pub(^s. 

One of the common n^sults of a difficult labor is to loosen the 
attachments of the vagina to the cer^'ix. As seen through a 
speculum with the patient in the Sims or knee-chest position, there 
appears to be little or no intra-vaginal portion to the cervix. In 
these cases the mobility of the uterus is increased and, other things 
being ec|ual, descensus is favored. The attachments of the vagina 
to the ccTvix si^ve to steady the uterus and keep it in its proper 
relation to the pelvic floor. 

The retro-uterine c(^llular tissue has probably very little influ- 
ence on tlu^ position of the utcTus unless it is the seat of inflamma- 
tory thickening; in which case it fixes the organ. It sometimes 
happens that wonuMi who are the* subjects of pelvic inflammation 
are relieved of pnM'xisting i)rolapse only to suffer with it again 
when the exudate has l^^en al)sorb(Ml. 

(c) The variations of pr(\'=^sure exert eil by the abdominal con- 
t(Mits. Tli(^ Holder is referred to Chapter V., page 45, for a partiid 
exposition of this sul)je('t. Here it is sufficient to say that we have 
to do with (1) downward ])ressun^ exerted by (a) increased weight 
of the nicms itsi^lf, {b) the weight of the intestines filled with a 
varying amount of solid, fluid, or gaseous matter, and (c) the 
weight of dislocated organs, such as the stomach or kidneys, or 
the w(»i»:lit of a tumor; and (2) additional pressure transmitted to 
the abdominal contents by the walls of the abdomen and by the 
diaphragm in contrliing, laughing, straining, jumping, and riding. 

The downward pn\<sur(^ spends itself under normal conditions 
mostly on the lower anterior wall of the alxlomen. By consulting 
Fig. G, page 44, it is apparent that the long axis of the abdominal 
cavity falls at nearly a right anglt^ to the long axis of the pelvic 
cavity, and that the pelvic viscera are protected in a measure from 



DESCENl' OR PROLAPSE 



223 



IMWure directed tlownwai'd from above by thr forward liuiibar 

curve of the spine, which, in the normal standing posture of the 

individual, must take 8omc of the weight of the contents of the 

alxiomen. A transvense .sectiim of the body of tlie Mlult virgin 

through the fifth lumbar vertebra ^hows that at this situation the 

depth of the aklominal cavity f 1*0111 before back is ver^' much le^ 

than it i^ in the upper portion of 

the alxlomen* For instance, it rej>- 

rt*?jents only a little over a third 

of the entin* thickneas of the liody 

if measured in the nuxtian line fnmi 

the anterior face of the lumbar ver- 

tebm to the ^kin j>urface8 of the 

front and Ijack of the l>ody. At 

the level of the twelfth doi-yal ver- 

t4*bra, on the other hand, the 

abtloniinal ca\'ity takes up over a 

half of the tliicknesB of the trunk 

if meai^iurd in the same way and 

occupies a major part of the cubic* 

contents of the Ixxly at this jmint. 

When tlie Iwu'k is flatternd and 
the forward luml>ar curve is more 
or le«s oblitrratcMl^as happens in 
the cajseof the tlat^hested, slouch) 
body |X)sture so often seen inwonjcn 
— more of the weight of the \iseera 
will fall on the inlet of the |X'lviH, 

Under normal conditions there 
is prewnt a thru^st directed forw^ard, inward, and do\\Tiward from 
thi? slanting surface of the brim of the false pelvis (60° with the 
horizon! that throws the abdominal pressure on to not only the 
Jow*er alHlominal wall, but also on ti»the posterit^r surface of the 
anteverted uterus and the backs of the wide expanses of the broa4:i 
ligaments, Tlius is the uterus maintained normally with its long 
axis at a right angle at least with the long axis of the vagina. 
Ab has been stat(»d previously* the axis (»f the utenis must be 
■ chaiige^^l to retroversion t»efore prolapH" can occur. Such a diangc* 



Procidentia. 



MpH tr Prulapse or 
t After Huguier.) 



224 



3L\LPOSmONS OF THE UTERUS 



chronic (Ii.stention of the urinan' bladder, chronic fukiess of the 
rectum, sudden jar, etc. (s^ee Retroversion, pwige 234). When 
once th<» axis has been changed, the intra-abdominal pressure is ex- 
erterl against the anterior face of the uterus and the broad liga- 
ments, and increased pressure accentuates the retroversion, and at 
the same time pushes down the uterus, now in the same axis as 
the vagina. Factors which make for greater downward pressure, 
such as a jK'rsistent cough or violent straining because of chronic 




Fig. H8.— Prolapse of the Va^iii:i and Cervix, with Elongation of the Supra- 
vaginal Cervix. 



diarrhea, tend to cause descensus uteri. Constant straining is an 
important faetor in the causation of prolapse; therefore prola|)se 
is found most freriuently among women of the working classics. 
These women an^ apt to gc^t up and Ix^gin work soon after con- 
finement wlu^n the uterus is large and heavy and retrovert^d. 

Inversion of \]w vagina may take place without actual descent 
of the ut(Tus because of the elasticity of the vagina, and, prolapse 
may Ix^ simulated by elongation of the lower uterine segment. 



DESC'EXT OR PRuLAPSE 



225 



True hiffferlnrphi4' elongation of the cervix j a lengthening of the 
I cervix and the lower segment of the uterus, is by no means an 

uneomTnon condition. In such a ea-^e, should the utero-pacral 

liganiexit.s, which ordinarily limit the amount of the descent of the 
I uUtus, prove to be strong and not susceptible of stretching, the 

fundus uteri may remain nrarly at its normal level whili^ the exter- 

Jiml OS presents at the introitui? vaginie. A typical vasi^ of true hyper- 
tropic elongation of the cervix was n.^ijorte*! by Hugnier (**Mcmoire 
sur les Allongements Hypertrophiques du Col de TUt^Jrus," 



iLJi 



d 



Fig. S8a. — Hypertrophic Elongation of the Cervix in the Virgin, 



,18641, p. 40) as long a^r* sis lSf»0. A woman tw(*nty-three years of 
?, of poor general health an<i physiijui*, married two years but 
never pregnant, pre^sented hersi^f for tn»atment because of pains 
in the abloinen, dyspareunia, and a tnmor in the opening of the 
vagina. Catamenia began at thirkrn and she noticed the pro- 
jection at the vulva at fourtii n anil a half yeai-s. It came out 
while she was staniling or straining and was rcHluced on lying 
down* Examination showetl the vagina only a little ^^hoilened ami 
£!Upic»fl by the enlargal cervix; fundus uteri only a trifle below its 




226 MALPOSITIONS OF THE UTERUS 

normal situation; and the uterine cavity measured five inches (13 
centimeters) in depth. 

Prolapse is largely a disease of women who have borne children. 
It is most conmion after the menopause when the utero-sacral 
ligaments are prone to be fatty degenerated, the other supports 
of tlie uterus have lost their tone, and there is increased abdominal 
pn^ssure due to increase in the size of the abdominal contents. It 
occurs hifrecjuently in the nulliparous woman and is then com- 
monly due to retroversion associated with chronic diarrhea or a 
long standing cough; or to incn^ase of alxlominal pressure from 
ascites or a tumor. It is probable that stretching of the utero- 
sacral ligaments and a conse(|U(»nt carrying forward of the cervix 
may r(\^ult from chronic fecal impaction of the rectum. 

Symptoms and Course of Prolapse. — ^I'he usual symptoms of pro- 
lapses are: Dragging pains in the pelvic region and difficulty in 
walking; frequ(»ncy of micturition and v(*sical tenesmus; inability 
to empty the rectum; leucorrhea, irritation, and pain from vaginitis 
or an ulcerated vagina; and stcTility. It may be necessary for the 
patient to stay in IxhI in severe cases — often all hard labor has to 
bc^ givcMi up. The course of the disease is chronic as a rule, though 
not hifn^quently complicated by attacks of acute vaginitis. Occa- 
sionally an attack of peritonitis, by making adhesions and thus 
fixing tlu^ uterus, has Ikhii known to (effect a cure. 

Diagnosis of Prolapse. — In establishing the diagnosis of prolapse 
we considcT the clinical history, and, in a less degree, the symptoms. 
Th(» woman is gen(Tally at the menopause or has passed it, is the 
mother of one or mon^ children, and belongs to the working classc»s. 
There is ordinarily a history of a preccMling uterine malposition, such 
as retrov(Tsion. Tlus appearance of a protrusion at the vulva on 
straining at stool or on oth(T ex(M-tion is often a sudden affair and 
may be th(^ first abnormality noticcnl. The cervix is disthigiiished 
from rect()C(^l(\ cystocele, cysts of the vagina, a fibroid polyp, or 
inverted uterus by tlu* pr(\^(Mice of the os externum. When the 
prolapses is established, the patient complains of pelvic pains, 
dysuria or fnuiuent micturition, difficult locomotion, and, if the 
rectum is involved in th(» descent, of inability to evaeruate the 
bowel without assistance from th(* hand. There may be inconti- 
nences of urine from overdistention of the bladder, and the pnv 
la{)sed mass may become ulcerated from attrition — in this cast* 




Frr.. 89. - Partial Prohipw of the Ithruriaud \ agin a. I Iju Lj^hl t^pot »SJiou,*> 
l}i«' 8it lint ion of th«- Tip of a Suumi ia the Biudder, Marking the Lowest Pomt 
of the Blttdrl<?r. (Kelly) 

If the j>rolapsi» is only partial an examination in the standing 
pr>:*ition i^hoiiIJ tx* mmh nlsn. the [mti<^nt t Hearing tlmvn so a^s to 
«irivc! out thr h<Tnia to its full exti'nt. TIhtc is i^Mom much 
^Uffieulty in making tht* diaKunsis, Tlit- iTuportant points are to 
*letprmiiir Ihr t*xtpnt of tin* ilownwani dii^loralion of tlic uterus*: 
iho rxact she, position, and shape of this organ; the {situation 



228 MALPOSITIONS OF THE UTERUS 

of bladder, urethra, and rectum — also the ovaries and tubes — 
and the amount of prolai)se and the condition of the vagina. In 
most causes of prolap^^o the* vagina becomes thickened to a marked 
degrt'e and takes on the characteristic of skin, and ulceration may 
develop in its structun^s. These items are to be noted carefully 
because upon th(»ni depc^ncLs the form of treatment employed and 
its success. 

A conjoined recto-ab<lominal examination determines the situ- 
ation of the fundus uteri. A sound passed into the uterine cavity 
shows its d(»pth, size, and shajx?, and whether or not any polypi are 
situated th(»re. The cleans(»il sound passed into the urethra shows 
the direction of the canal and whether any portion of it is dislo- 
cated do\Miwanl and, if so, how much. It also shows the limits 
of the bladder in the prolapscnl mass by noting the situation of the 
point of the sound on the vagina both by sight and touch. (Sec 
high light in Fig. 89, marking tip of sound in bladder.) A finger 
hooked through the anus .shows whether the rectum has been dis- 
located downward. It may Ix^ possible to palpate the whole of 
the uterus outside the vulva through the walls of the inverted 
vagina, but in most cas(»s, for the purjXDses of diagnosis, it Is best to 
reduce tin* prolaps(\ This is done by covering it with muco- 
lubricans and making g(»ntle upward pn^ssure, at the same time 
squeezing the mass a littl(% and in some castas it may be necessary 
to place th(» patient in th(» knee-chest position before resorting to 
this nu^asure. When the mass has been reduced a bimanual ex- 
amination is made with the patient in the dorsal position and the 
size and shape of the utcTus mappc^d out anew. It is now possible 
to (letennin(» true hypei-trophie (^longation of the lower segment 
of the uterus, fibroid no(lul(\^, the location of the ovaries, etc. If 
th(^ vaginal walls are much thickened the tactile sense of the ex- 
aminer's finger will Ix^ blunted. In this event a recto-abdominal 
examination will i)rove to Ix^ more satisfactory. 

Differential Diagnosis of Prolapse. — An inverted iderus may be 
mistaken for a prolapse. The absence of a distinct ring having a 
sharp edge coni{)letely surrounding the i)rolapsed mass, and the 
fact that at no {)oint can a sound be passed into the tumor, sen'c 
to distinguish the two. If th(* alxlominal walk happen to be ex- 
treuK^y thin a eui>shaped deprc^ssion in the abdominal aspect of 
an inverted uterus may be made out by bimanual touch. 



True hypertrophic elongation of tlie lower uterine segment (Fig, 88a) 
has been spoken of as a part of prolapse. It is clijignosed by cli&- 
tingui.shing unusual k*ngth of ttie lowrr part of tin* uterus by bi- 
manual touch, by finding a fundus placed relatively high in the 
pelvis, and Increasixl length of the cervical canal, as disclosed by 
in«ii<uring the sound passed only to the internal os, — the point 
where the tip meets an obstruction. Wlien the |mtient is placed 
in the knee-eh(»st |>osition the cervix 18 not obliteratcHl, as under 
normal conditions. True hypertrophic elongation occurs only in 
sterile women; falst^ hy|)ertrophic elongation, occurringin the i>arous, 
is ilescribed in the chapter on laceration of the cervix, page 209. 

A pedunculated fibroid or polypm is sometimes mistaken for a 
prolapse. In this case a soimd can be swept about in the uterine 
cavity at any point in the circumference of the collar of the cer\ix 
except at the side wliere the polypus is attached to the literine wall. 
There is no cavity in the polypus, and recto-ablominal touch re- 
veals the presence of the fundus uteri in its normal position. 



I 



t 



3. Antkrofosition 

Anteroposition of the uterus, or a utenis jilaced as a whole too 
near the symphysis jjubis, is due to retro-utiTine tumors, such a^ a 
pehic hematocele, dermoid ovarian tumor, or tumor of the rectum, 
or even an overloaded rectum. As far a^ we know, this position 
of the uterus is of no significance from a pathological or clinical 
point of view. The diagnosis is established l)y the bimanual 
touch; noting that the uterus is not in its normal situation but 
dose against the pubic arch, 

4. Lateroposition 

f 

The uterus may be displaced to the right side or to the left side 
by a tumor or an inflammatory mass, the uterus Ixnug puslied to 
the opposite* side of the pelvis to that occupietl by the tumor mass. 
CiciUricial contraction folloviing an effusion in one Ijroad ligament 
may draw the uterus to that side of the [X'his. Such a malposi- 
tion is to be noted for the purpose of removing its cause and 
hae significance only because of the jmthological condition pro- 
ducing it. 




230 



MALPOSITIONS OF THE UTERUS 



o. Rktroposition 

This is an important malposition which is almost always attended 
by dysmenorrhi^a. It is often spoken of as retroversion and also 
as anteflexion. Dissimilar as these abnormalities api>ear to be, 
th(Te are comparatively few cas(\s of retroversion or anteflexion 
that do not have a certain amount of retroposition. The placmg 
of the uterus backwanl near the sacrum seems to be the important 




Fig. 90.— Anteflexion in the Little Girl. (Schultze.) 

factor in the causation of symptoms. The immobility of the uterus 
in this position is undoubtcnlly the chief factor in the causation of a 
large class of cases of antc^Hexion, and the fixity of the organ close to 
the hollow of the sacrum, rather than its anteflexion, is the deter- 
mining elcMiient in the production of the symptoms from which 
patients with these abn()rmaliti(\^ suffer. The retropositions asso- 
ciat(Hl with retroversion will be taken up under the head of retro- 
version. Here we will discuss the very common uterine disease, 
retroposition with antc^flexion. 



RCTRcmxsmoN 231 

Retroposition with Anteflexion.— By reference to tlir figure 
taken from IIS. Shultze^ '* Displaeenients of the ri(^ruH/* Fig. 90, 
it will h' note4 that in the little girl — the bladtler and reetuin Ixing 
empty — the uterus Ls normally in a state of anteflexion; that the 
vagina is relatively long; the long axis of the cervix — also long with 
refen*nce to the k*ngth of the* corpus — \^ nearly in the axiij of the 
vagina; the intravaginal anterif>r \\p of the cervix is short; and 






■^ 



I 

Fio. dl. — Pathological Anteflexion Arising from Coatmction of the I'tero- 
LigatnenU {a) Dirt-rHoD of flit* l*iill t»f rhe Ligaments. (6) Direction 
P^fbo Intra-abiloniinal Pressure. tScliuItste. ) 

the n^gion c»f the internal os is high up, Ixthusc the entire ntt*rns is 
in the falw^ peKis, and is near the sacrum. The ntenis is not fixeilp 
howrver, in this [josition* Tiiis condition, then, is nomml to the 
growing girl li^fon* lailxTty, 

Fig. 91 shows retroiMisition with anteflexion, the old so- 
callini *- pathological anteflexion/' The siniilarity of the two 
conditions is striking, and it seems fair to draw the inference that 
retroi)08ition with anteflexion is a pc*rsistence of the puerile stat<*. 




232 MALPOSITIONS OF THE UTERUS 

with the addition, in the case of retroposition with anteflexion, of 
adhesions limiting the mobility of the uterus. 

Anteflexion may be accjuired, however, as in the case of a uterus 
with softened tissues having a fibroid in the anterior w^all of the 
fundus. Excessive straining at stool tends to bend the cervix 
forward and at the same time to fold the fundus and body of the 
uterus forward and downward, pro\nded the forward excursion 
of the region of the internal os is limited. Thus a flexed uterus 
becomes more flexed. The uterine caiial is obstructed mechan- 
ically at the internal os by excessive flexure, therefore we should 
expect these patic^its to suff(T with blood stasis and endometritis, 
the results of a damming up and d(*composition of the uterine dis- 
charges, and this is usually the case. 

Vesical symptoms aiv due to the backward traction of the cervix 
on the vesical neck and to the* interference offered by the forward 
flexed fundus uteri to the filling of the bladder. Of the two the 
former is the more important cause. 

I have previously callcnl attention to the frequency of retro- 
position with anteflexion ('^Division of the Utero-Sacral Liga- 
ments and Suspensio Uteri for Immobile Retroposition with Ante- 
flexion,'' Ainer. Gyn. and Ohstet. Joiir.y Jan., 1898, and '^Furthtjr 
Experi(*nce with th(^ Operative Tn^atment of Anteflexion,'' Arner. 
Gyn. and Ohstet. Jour.y Jan., 19(M)). The condition has not been 
recognized g(*nerally by the profession, having been classed broadly 
SiS retrovi^rsion. 

Diagnosis of Retropos^ilian with Anteflexion. — ^The diagnosis is 
made by finding the uterus as a whole in the extreme back part of 
the pelvis. This is doru? by practising the bimanual vagino- 
alxlominal or recto-alxlominal touch. The cervix is in the axis 
of the vagina, the anterior lip is flattened and short, the crown of 
the cervix being in extreme cases practically continuous with the 
front wall of the vagina. The cervix, in the axis of the vagina, is 
not so long, a.s a rule, as in the case of the puerile cervix, but it is 
long as compared with tlu^ fundus, representing two-thirds of the 
entire length of the uterus. Its tissues are generally indurated 
and more or less tcnider; there is a cervical discharge from a pin- 
hole OS. The fundus is flexed fonvard and may be grasped be- 
tween the forefingcT in the vagina and the fingers of* the hand on 
the abdomen. It may be (enlarged or it may not, and tenderness 



HERNIA OF THE ITERUS 



233 



on pressure and induration are not necessarily present, Shortcnetl 
irtf»ro-sacral ligaincmt^ or extraliganientous aclhet^ions — ^these latter 
rarely pret^nt — limit the for^vard exfur8ion of the uterus as de- 
temiined by making fonvard traction with the examining hamb. 
Rigidity of the tissues at the angle of Hexion is det<*nnint^l by 
manipulating the litems. Downward pressure on the fnndus by 
the hand on the abcioinen moves the cervix baekward, and up- 
ward pressure on the fundus by the finger in the vagina moves 
the cervix fonvard. It is im|)OHsible to change the relation of 
cervix and fumlus to eaeh other by separating two fingers placed 
between them in the vagina. 

As a rule it i^ not necessary to pass the sound in order to verify 
the diagnosis. In fat women, however, with thick and rigid 
abdominal w^alls, this proeerlure may be necessary. Select a flex- 
ible Bcjimd of small ealibT. This is lictter ami safer than a probe, 
the tip of which will catch in pockets of the lining mucous mem- 
brane. Bend the sound so that it rorres|K)nfls to the bent uterine 
canal as detcnnine<l by jialpation; fix the cf»rvix wuth a tenaculum 
and make gentle traction, thus straightening the uterine canal as 
much as ]X)8sible. Pass the sound tentatively, withdraw^ and 
rebt*nd, until the tip will slip through the internal os. Note the 
[K>int of sensitiveness in the uterine canal, if any, the distance of 
the internal os from the external os, and the total depth of the 
uterine ca\ity. Note thus thi* relation that the length of the 
cervical canal lx»ars to the length of the uterine cavity proi>er: 
also consider the tightness of the internal os, the capacity of the 
uterine cavity, and the amount and character of the dis<:harge. 
If blood follows the gentle passing of the sound and tenderness is 
pn-H-tit, one may diagnose endometritis. 




(k Hernia of the Utkrus 

Hernia of the uterus through the inguinal or the crural canal is 
a rare anomaly. The diagnosis is established by determining the 
absence of the uterus from its nornial situation and its presence in 
the hernial sac. The latter is a most diiticult matter and most of 
these eases have b<x?n operated on for strangulate<l hernia, when 
the diagnosis was made. Congestion or tumefaction of the hernial 
tumor cont^ning a uterus should be looked for at the time of 




234 MALPOchITIOX.S «»F THE ITERUS 

meastruation. If the displace*! utera< becomes pn^nant — as it 
has in a few ca<es reixirtc^nl in tin? literature — the tumor becomes 
I>rogrr»ssively larj^r-r as pregnancy arlvances and the symptoms and 
signs of pregnancy are present. 



11. ABNORMALITIES OF THE AXIS AND FORM OF THE UTERUS 

1. Retroversion: Ret roversio-flexion. 2. Anteversion. 3. Ante- 
flexion. 4. Inversion. 5. Torsion. 

1. Retkoversiox 

Retroversion is that abnormal position of the uterus in which 
th(» h)ng axis of the organ is tilted backward to or beyond the long 
axis of the vagina. Retroflexion signifies the bending backwanl 
of the fundus and body alone — a flexing of the utenis — and there- 
fore a change only in fonn. Retroversion and retroflexion are 
commonly associatcnl. Th(»y p^^s(»nt similar patholc^cal condi- 
tions lyoih as regards the tissues of the uterus itself and the sur- 
rounding organs; th(nr symptoms are the same; therefore, they 
will be consid(T(»d together. 

Retro versio-flezion. — This is one of the commonest uterine mal- 
positions. As has \xvn pointed out in describing the mechanics 
of prolapse, in order that the ut(TUS may be retro verted it is neces- 
sary for the cers'ix to leave* its normal position — ^it must move 
forward — for with th(» cervix normally situated there is not suffi- 
cient room for the fundus and body between the cervix and the 
unyi(*l(ling sacrum. RetrovcTsion, then, presupposes a stretching 
of the utero-sacral ligaments. Any abnormality tending to draw 
the c(Tvix forwanl will figure as a cause of retroversion, such as a 
bad vesico-vaginal fistula, and chronic cystitis with contracted 
bladder, thus shortc^ning the anterior wall of the vagina. This, 
fortunately, is an unusual condition. Congenital retroversion is 
very rare, but aftcT the menoi)ause the small senile uterus is found 
freciuently in this position. R(»laxation of the uterine ligaments 
is the chief cause of retroversion. AddcnJ to this are : habitual 
dist(*ntion of the l)la(l(ler: chronic distention of the rectum; in- 
creased weight of the uterus; retro-uterine peritonitis; adhesions 
jmlling back the fundus; chronic cystitis, with contracted bladder; 



RETROVEItSlON 



235 



i^umll myoma in iU- iitistcrinr wall of the furultis, and siuldt'o 
^i^aimng or a violent fall. \\ Inn once the axi.s of the uterus ha.s 
bet^n tiirneil Imckwanl Wiry act of (It^foration or straining tnmLs 
to jmsh the funikis furtiier tow an 1 thr sjwruni l)ri*un.s(.' the thru^«t 
I of tin- intra-al>tloiinnal jm^ssnre acts on the anterior rather than 
on the posterior fare of the funchis. It Is |>rnlml>lr tliat hackwaixl 
tilting of the jielvis on the s|>ine, with tlaitr-ning of the foi-w^anl 
lumlrnr eurv(* of the ^imv, due U) faulty attitude while standing, 
Imssometliing to do with the eausation of this uterine niali>osition, 




Fto. 92. — Retroversion of the L'tenis, 

for if the plane of the peMc inlet becomes more nearly horizontal 
antl at the* same time the inlet is not protected from atxivc^ by the 
forwunl i)roj(>etion of the lumbar sj>iiH% the intra-alxlomijuil pn»s- 
5»tire b tran^mittetl more directly to the contents of the pehis and 
from a more forward tlireetion. Tliis pn*ssun* from the front is 
«ic«H*ntuate<l by tlie contractions of the alxluminal muscles in strain- 
ing, thus throwing backward large masses of intestine from a pro- 
tuberant abiomen. which is often jjresent, in these cases, 

Thr puerperiun), with its lax^ non-involuterl utrrinc ligaments, 
ilicreast»d weight of the uterus coujileil witli tlie normal retrover- 
l^n from the patient's recumbent ^>osition, \b a pecuHarly favor- 
able time for the nuiI(K>sition to Ix^gin. It is not easy to explain 
the causation of retroversion seen so conmionly in young unmar- 



236 MALPOSITIONS OF THE UTERUS 

ried women. Possibly habitual constipation and overdistention 
of the bladder and faulty posture may have something to do 
with it. The symptoms of retroversio-flexion are not distinctive 
and there may ho no symi)toms. If present, they are: a sense of 
weight in the pehis or b(*aring-down feeling, irregularities of men- 
struation, uterine catarrh, constipation, frequency of micturition, 
and abortion and sterility. In the case of retroflexion, if preg- 
nancy occurs in the n^troflexed fundus there is less likelihood of 
spontan(»ous reposition than in retroversion, and therefore abortion 
is more likely to occur. The bladder and rectal symptoms are 
apt to be more pronounced in retroflexion than in retroversion 
because in the former there is more dragging on the neck of the 
bladder and a sensitive fundus impinges more directly upon the 
lower rectum. The degree of retroversion is a variable quantity. 
Formerly it was customary to define the amount of tipping of the 
uterine axis with great exactness and the retroversion was said to 
be in the first, second, or third degree, according as it w^as tipped 
backward so that its long axis pointed, respectively, at the promon- 
tory of the sacrum, in the axis of the vagina, or it exceeded the 
last amount of tilting. Now we consider the okl first degree to 
be within normal limits. It is well, however, to preserve these dis- 
tinctions for purposes of description. 

Diagnosis of Retroversio-flexion. — ^The bimanual touch shows the 
fundus to lx> absent from its normal situation and the cer\ix in the 
axis of the vagina. If the abdominal walls are thin and relaxed 
it is possible often to i)alpate the fundus bimanually, even though 
it is n^troflexed. In less favorable cases the hand on the abdomen 
determines the al)s(^nce of the fiuidus in its normal position. The 
fing(T in the vagina notes a sense of resistance in the cul-<le-sac, 
or in th(* case of retroflexion, a rounded body in that situation. 
Rectal touch is of great assistance in the diagnosis of both retro- 
version and retroflexion, for by the rectum the examiner's finger 
can reach a higher point in the pelvis than by the vagina. One of 
the most inipoi'tant facts to determines is the mobility of the uterus; 
therefore attempt to dislodge it. To do this, make an upward pres- 
sure on th(^ fundus by the left forefing(T — protected by a cot — ^in 
the rectum while thc^ cervix is pushed backward by the right fore- 
finger in the vagina, th(^ i)atient l)eing in Sims position. If this 
is unsuccessful, hook a t(*naculum into the cervix and make down- 



RETROVERSION 



237 



ward traction while the rectal finger pushes the fiimliis up. If 
the fiindu.s ha^ been displaet^l from the hollow of the saerum by 
thest* manipulations the tenaeuluiii is reniovt*(l from the eenix, the 
left forefinger — the eot having l>eeii removed — is transferivd to 
the vagina, the right hand is passed between the patient's thiglis 
to the abdomen and the uterus rocked into place b)' the bimanual 
touch. The knet^ehest position and traction on the eemx with 
a tenaculum will ohvii accomplish tln' reiK)sition of an olistiiiate 
rntrowrsion or an incarcerated pregnant funtlus. Sometimes the 
dis]ilaee<l fimdus is ht^ld Ix-t ween the utero-sacral ligaments. Wlien 
the uterus is raised in the pehds these ligaments are relaxeii and 
the funtlus may lx» piL^he^l up through them. In some eases, es- 
j>ccially in virgins with tense, well-developed abdominal walls, noth- 
ing short of an antithetic will permit reposition of a retroflcxeil 
utiTus even though free from adhesions. During the manipu- 
lation the physician gains a knowledge, through his sense of touch, 
of the other (x-lvic organs. He detects sjilpingitis or thickenings 
denoting adhesions. He notes points of tenderness, and these warn 
him against \ngorous attempts at rej>osition. When the Peaslce 
rigid uterine sound was first inventetl it was customai-y for the 
prai'titioner of that flay to pass it into the uterine cavity and 
forcibly pry the uterus into placf, and the trauma, together with 
the lamk of asepsis which iirevaikHl at that time, produce*! most 
dinaiStrouB result^^ in the form at twnte peKic inflammation, salpin- 
gitis, or even jM*lvie alwess. 

SupjKPS*^ th<* fundus has bf»en frf*e<l from its abnonnal position, 
the next procedun^ is to hold the cer\ix backward while you resell 
for the fundus with the fingers of the right ham! on the alKlomen, 
working tliem b-hind it by gradual ami re|_M^ated pressure as the 
imtient takers d(M^p inspirations. Backward pi*(\ssuR* on the cervix 
and fonvard rocking on the fundus restort* the uterus to its nornud 
pofidtion. The Irimanual touch practiced in the Sims j^sition is 
meet useful for this pnx't*thin*. Always 1m* sure that the bladd*'r 
\h i^mpty before lieginning the mam'pulations. If the uterus comes 
up do the ovaries alsti assume a normal jxjsition? Note their size 
as well as thpu* moliility. In exceptional cas(»s the aseptic sound 
may be passixl to confirm a tliagiiosis, esi>ecially in castas of retn> 
flexion. Here it is generally necessary to pass a sound to differ- 
entiate from a fibroid in the [>osteiior uterine wall. It is necessary 



238 MALPCXSITIONS OF THE UTERUS 

to exclude ail inflainniatory mass or abscess ix)sterior to the uterus, 
and this is done by noting the shajxi and situation of the inflamma- 
toiy mass. Recto-abdominal touch shows it to be situated in the 
recto- vaginal s(^ptum, and it is generally a little to one side or to 
the other, and not, like the retroflexcnJ fundus, directly in the 
median Hne. A scybalous mass in the rectum is detected by 
rectal touch. In doubtful cases cleanse the rectum by a suds 
encnna. 

In diagnosing retroversio-flexion it is often not advisable to make 
a comi)lete diagnosis at one sitting. Sometimes the best plan is 
to i)ack the vagina with cotton tampons, cleanse the bowel by a 
cathartic, and see the patient again after a lapse of two days, 
when it will \x} found that a retroveileKl uterus has been replacc^l. 
In other cases the* j)resence of pehic inflammation or salpingitis in 
a chronic stage makers replacement inadvisable. In such cases 
tn^atnu^nt with glycerin tampons, vaginal suppositories, and 
douches is to Ix^ employed until the subsidence of the inflamma- 
tion. After a second or third examination the physician will have 
a l.x»tt(M' id(^a as to th(» pathological condition of the pelvic organs 
and will Ix' in a {position to advise, if necessary, etherization for a 
compl(»t(» diagnosis. Progressing too fa^st or too vigorously has 
often done great damage by lighting up dormant inflammation, 
rupturing adhesions, and causing hemorrhage, or scjucezing jjus 
from inflanuHl tulx's. 

2. AXTKVKHSION 

This is of Hltlc* importance clinically and is to Ix) classed with 
lateroposition or lat(T()V(Msion. Sometimes freciuency of micturi- 
tion is found in cjises of antevei-sion : in this case it is due, appar- 
ently, to traction mmh* on the neck of the bladder by the exagger- 
ated posterior position of the cervix, for the symptom is done 
away with by elevating the fundus with a Hodge or Gehnmg 
p(\^sary. Tlu^ diagnosis is established by the bimanual touch, 
the fundus Ix'ing found w(^ll down Ix'hind the symphysis pubis 
and the ci^rsix high in the pelvis. The axis of the uterus coin- 
(»id(\^ very nearly with the axis of the vagina in extreme degrees 
of antevei-sion. 



240 MALPOSITIONS OF THE UTERUS 

3. Axtp:flexion 

Anteflexion has bc»en describcHl at length under Rctropo^tion 
with Ant(*flexion. It is to be understood that this malformation 
of the uterus does occur without the posterior malposition. What 
has been said of the combined disorder applies equally to the 
flexion alone. 

4. Inversion 

Inversion of the uterus is a partial or complete turning of the 
organ inside out. It is of three sorts: (1) acute puerperal inver- 
sion, (2) chronic puerperal inversion, and (3) inversion caused by 
uterine tumors. The first sort concerns the obstetrician. The 
second is th(^ more usual of the remaining two forms that are seen 
by the gynecologist. 

Pu(»ri)(Tal inversion is due to relaxation of the uterine muscles 
at the time of the delivery of the placenta. Coughing or sneezing 
may invert a relaxed uterus; too nuich traction on the cord and 
an adherent i)lacenta are the direct causes in some cases. The 
uninvertal part of th(» ut(Tine wall may s(»ize the inverted part 
so that th(> uterus looks like th(^ lx)ttom of a wine bottle, and the 
contraction of the* unrelaxed portion may continue to push the 
fundus downward until th(» uterus is completely inverted. The 
process may start in the l()W(»r utcTine segment, which is inverted 
first, and is followt^d by tlu^ fundus. The tul:H\s follow necessarily 
into tli(^ cup of the* invi^-ted fundus and sometimes also loops of 
int(\stin(^s, ])ut tlies(» structures are seldom adherent. The evert<Ml 
nuicosa of the uterine cavity is dark red and bleeds easily, and in 
cases of Icjng standing inversion it shows regions of ecchymosis 
and ulc(»ration. Cases have l^ec^n reported where there were ad- 
hesions l)(*tween thc^ partially invc^rted fundus and the cer\ix. 
If invt^rsion is due to downward traction on the uterine wall by a 
submucous fibroid th(*rc is apt to he present a foul uterine dis- 
charge, for tlu^ fibroid is generally in a state of necrosis. The 
usual sym[)t()ms of cl ironic invei'sion an?: jK^lvic pain, hemorrhage, 
leucorrh(»:i, fn^ciuency of mi(;turition and dysuria, and difficulty in 
walking and standing. 

Diagnosis of Inversion. — In favorabk^ cases where the abdominal 
walls arc relaxed and the patient is not fat, the bimanual touch will 



242 MALPOSITIONS OF THE UTERUS 

show the absence of the uterus in its customary situation. Rectal 
touch is of great use*, also the recto-abdominal touch, and the 
rectal touch with a sound in the bladder. In extremely favorable 
cases the depression of the inverted cup may be made out by the 
abdominal hand. By vagina the partial or completely invert<Hl 
uterus is felt and seen, and occasionally the orifices of the Fallopian 
tubes can be demonstrat(*d in the inverted fundus. The ring of 
the cervix can b(^ felt by th(» finger swept about the inverted fundus. 
The difficult point in diagnosis is to differentiate complete inver- 
sion from submucous myoma. 

By reference to the figures on page 241, it will be seen that a 
myoma may si)ring from tlu^ fumlus, body, or cervix. It may he 
sessile, or have a short [XMlicle or a long one. Fig. 100 shows 
an unusual condition: a jxHlunculated subperitoneal fibroid at- 
tached to the cervical region — the uterus being in a state of com- 
plete inversion — and the fibroid tumor presents to the examiner's 
touch the size and shape of a uterus in a normal situation. Li 
such a case it would be extremely difficult to tell the uterus from 
the tumor. Detection of the orifices of the Fallopian tubes and 
also the ring of the cervix would Ixi the distinguishing features. 
Complete prolapse can be difi'erentiated from an inversion by 
finding in the pr()la[)se the ext(M*nal os uteri; the extruded mass 
is widc^r above and narrower Ix^low; and the vagina is everted to a 
greater or less degree, as sliown by iho. fact that the point of a 
sound introduced into the bladdc^r can be felt in the hernia. In 
the case of inversion, on the other hand, there is no external os, 
the orific(\s of tlu^ tubes may \yo seen, and a sound in the bladder 
goes ui)ward, except vcTy rarely when the vagina also is inverted. 

Differential Diagnosis of Inversion. — The following is a tabulated 
statement of the (liff(»rential diagnosis between complete inversion 
and pedunculated fibi'oid in th(^ vagina, and incomplete inversion 
and intra-uterine subnuicous fibroid. 

Complete Inversion. Pedunculated Fibroid in Vagina. 

1. Sweeping finger and sound alx)ut 1. Tumor is atUiched at one point by 
tumor shows it to have no point of at- a broader or narrower attachment, 
taehment. Verify location and size of attachment 

by the sound. 

2. Sound will enter ring of cervix but 2. Sound goes to fundus a distance 
a short distance. of 2} inches (six centimeters), at least. 



T0R8I0N 



243 



ComidHe Inverrion. 

3» Uterus absc?nt in abdomen ti> bi- 
manual C'xamtruAtioii. 

4. Ifrmiu masH is symnietricaJ, bir- 
ger bi'low and imrrower alM>ve. 

5* Orifict'a of the Fallopian tu1>es arc 

Ioft^i dcmoii!Jtrabic. 
Ineamplde Jnver&imt. 
1. Uterine cavity in shallow as meas- 
ured by sound. 
2- Cup-sbapcd depression in uterus 
fell bimanuiilly. 
:i. Symptoms date from part urit ion, 
CO 



Pcttuncultdcti Ftbroid in Vnginat 

(coniinued) 
'A. I'lLTus i>n.*8init in nbiomen. 

4. Mass may be asymmetrical. 

,'i. No orifices of (he Fallopian tubes. 

Intra-Uterint SuhmumttM Fibnmt, 
K Cavity deep. 

1\ No eup-ehaperj duprcMsion, 

3. Byrnptoins do not date from par- 
turition. 



a ToRsio.v OF THE IItebus 



Torsion, or twisting of the uterus on its own long axis, may l>e 
complete or it may Ix* pnrtial. In thi* ftirini*r thi* entire uterus is 
twiste*] to one side or the other, generally not more than half a 
H turn, as in the east.*.':^ of anteflexion or retroflexion where one 
I utero-saeral ligament is shortemnl. In the case of tumors growing 
from one side of the pc*lvis, however, the uterus may be twisteil 
aeverat times on its own axis. Torsion of the uterus oecun^ing with 

I a fibroid of subsemus evolution, or an ovarian tumor haWng a 
short pedicle, is generally partial. The cervix uteri, bnng steadied 
bj" the insc^rtions of th(5 broad ligaments, is not so ajit to parliei- 
mte in the twist and ttie uterus is twsted on itself, the fimdus 
iiid botly alone taking part in the twist. 
Torsion is especially ajit to be foun<l in the case of double uterus 
m uterus bieornis. 
The diagnosis Is made by determining l*y the bimanual touch 
the j)Osition of the? ovaritis and also tht* situation atul direction of 
the tran^'crse axis of the fundus with reference to the cer\ix. In 
the event of comjileti' torsion of the uterus the transverse axis uf 
ihe external os niay l)e He<*n tlirough the vaginal s]X)culum tf) Ik* 
turned away from the normal. 




CHAPTER XV 

THE DIAGNOSIS OF FIBROID TUMORS OF THE UTERUS 

Definition, p. 244. Patholog\', p. 244. Classification, p. 245. Situation, 
p. 248. Frequency, p. 248. £tiolog}\ p. 250. Course and Develop- 
ment, p. 251. Degenerations, p. 252. Complications, p. 255. Effect on 
neighboring organs, f). 257. Effect on distant organs, and on the system, 
p. 258. Relation of fibroid tumors to heart disease, p. 259. Dangerous 
to life, p. 260. SMiiptoms, p. 260. Symptoms of adenomyoma, p. 262. 
Diagnosis and differential diagnosis, p. 262. Subserous fibroids, p. 262. 
Intraligamentous fibroids, p. 263. Interstitial fibroids, p. 263. Submucous 
fibroids, p. 264. 

DEFINITION 

Fibroid tumor, also called myoma, fibromyoma or fibroma of the 
uterus, is a nodular growth developing from some portion of the 
uterus, usually, but not always, above the cervix, varying in size 
from a minut(^ si)eck to a mass or masses filling the pelvic and 
abdominal cavities. 

PATHOLOGY 

The largest fibroid which I have found recorded was one re- 
moved at autopsy from a single woman fifty-three years of age 
by S. H. Hunt of Long Branch, N. J. {Amer. Jour, Obstet., 
1888, XXI., J). 62.) It weighed one hundred and forty pounds 
and the cadaver after the removal of the tumor weighed ninety- 
fiv(; pounds. 

Tlu^ tumors are gc^nerally round in shaj^e, with smooth surface, 
but may bo i)(*ar-shaped, kidney-shaped, mulberry-shaped; may 
b(^ molds of the pelvic cavity, or, verj' rarely, may resemble a 
fetus. Th(*y are singh^ or multiple, as many as one hundred and 
fifty tumors having Ixm'u found in the utenis by Bland-Sutton. 
{Bvit. Med. Jour., April 0, 1001.) They are of a hard consistence, 
though a ])red()nnnance of nniscular tissue in their structure, or 
degenerative changes, may render them softer. They are classed 

244 



CLASSIFICATION 



245 



I 

I 
I 

I 



as lx»nign tumors l>ecause they do not ^'eat up*' the BuiToundiii^ 
tissues by extending into their suh<tance, and they do not cause 
de^tnietion l\v nieta.stases. They are conipuscd of the same tissues 
as the uterus, nanM*ly, unstri{>etl niuisele fil>ers and connective 
tissue. On section a fibroiil tumor is of a glistening white, or 
whitish-yellow color and is 5f*en to \w made up of a disorderly 
intertwining of muscular and ronneetive-tissue filxTs. In the larger 
masses, however, thes4* are grouiHMl iti more or less well-defined 
whorlB (see Fig. lt)6) winch somewhat resemble knots in a piece 
of wood. Betwt»ini the groups of filx^rs run ailerieSy veins, and 
lymph channels derived from the normal vessels of the uterus, 
ramifying at first beneath the capsule of the tumor and then 
plunging dirc^ctly into its interior. As a rule the,se tumors are 
poorly nourished because they derive their blooil from the sur- 
rounding constrictefl uterine tissue. Occasionally they are sup- 
plied by large vessels through adhesions to surrounding organs. 



CLASSIFICATION 



Fibroid tumors may be classified according to their situation \^ith 
fen^nce to the uterus. They are — 

1. Subserous, 
(a) Intraligamentous. 
(6) Tumors of the cervix. 

2. Interstitial. 

3. Submucous. 
They are deseribxl furthfT by defining their number and size, 

id by noting any special kinil, as ailenomyoma. For instance, 
in Fig. 102 we see a spei^iinen of a multiple fibroid uterus: an 
interstitial fibroid of the anterior uteiine wall, a subserous fibroid 
springing from the fundus uteri, ainl an inteivtitial tumor of the 
posterior wall. All fibroids originate in the uterine muscle, there- 
fore all are interstitial in the beginning. If tlje tumor develops in 
the outer wall of the utenis anri grows from the uterus under the 
peritoneum, it is calletl an adenomyoma. 

Adenomyoma is a special variety of myoma characterized by the 
.•l^rcsence of glands similar to those found in the uterine mucosa. 
Thomas? S, Cullen (*' Adenomyoma of the Utenis," 1908) found 



246 



DIAGNOSIS OF FIBROID TUMORS OF THE ITTERUS 



7^ cases of iKlciioinyoma among 12S,'i easels of niyoina oxamineil 
niicroscopically in tlu* Johns IIoj)kins Ilosi)ital Surgical- Patho- 
logical LalK)ratory during thii-toen years, or 5.7 per c(»nt of all 
fibroids. These tumors are diffuse and may or may not be definitely 
encai)sulat(Hl. 

1. Subserous Fibroid Tumor.— Such tumors have the greater part 
of their perii)hery outside the ut(Tine wall and have no considerable 
covering of uterine tissue. (See Fig. 102, upper tumor.) The 




I'ic. 102.— Multiple Fibroids, One Subserous and T\v'o Interstitial. (Winter.) 

greater tlie size of the sul)ser()us tumor the more it is separatc^l 
from th(^ ut(M-ns, as a rule. It may l)e relatively small or large. 
If, instead of (level()])ing under th(^ s(*rosa, the tumor separates the 
folds of the broad liganu^nt and distorts th(^ viscera to a greater or 
less degree, it is called an 

(a) Intraligamentous Fibroid Tumor. (See Fig. 105.) — These 
tumors have the greater ])art of their circumference outside the 
ut(Tus and are not covered l)y uterine tissue. Noble (" Gjmecolog}' 
and Abdominal Surgery," II. A. K(^lly and (\ P. Noble, 1907, p. 669) 



CLASS IFTCATION 



247 



fouiif! this form of tumor in 3,5 |x*r vimi of the 2,274 L'ases of fibroiil 
tumor he studied. The same rharat*t(Tii!ftics belong to 

(/;) TumoFfi niiich orlijinfile in the hiver po.steriiyr sctpnctit of (he 
ute)*iui and grow into the cervix mu\ then into the j»osterior jielvis, 
or tliase rare* tunioi*R wliieh orifj:inate in the cvvxix itself anil de- 
velop away from the uteni.s. i^cv Fig, 108,) The cervix, to 
bt* sure, has no covering of peritoneum. A.s the tumor increai>i\s 
in size and tiugs in the pelvis it puishes the peritoneum before it. 
Therefore^ this class of tmiiors may \je iJicluded among the 8ub- 



'/ 




I 



Fig* ll)3> — Large Multinodular 8iibiifritom«al rH^roul with Thiti Abdominal 
\V:ilb. 8wn in ProfiJe, (Kelly J 

US, In sul>siTou.s fibroids llic utrrine cavity i« altered little if 
all in length or shape. 

2, Interstitial (intramural, intraparietal ) fibroid tumors are those 
which ai'e situated in the wall of the uterus and are siu'rounded 
by a covering of uterine musculature. (See Figs. 102 and 104,) 
They may or they may not alter the contour of the uteruj^. Tlic 
uterine cavity h almost always lengthened, ami it may Ix* broad- 
eni^I anti made asynimetrical in shafx' by this fonn of tumor, 

3, Submucous Fibroid Timiors,^The.sc* are the tumors which dc^ 
velop into the uterine cavity imd are covered with mucous mem- 
brane and with little, if any, of the uterine miLsculatun*. (S«X5 
Fi^, 104 and 106.) Of ail the three varieties these cause the 
great e;4t changes in tlie form of tht* uterine cavity. These are 




248 DIAGNOSIS OF FIBROID TUMORS OF THE UTERUS 



the bleeding fibroids. The pressure exerted by the tumor on 
the nervous mechanism of the uterus set^ up reflex uterine con- 
tractions producing a gradual deliver}^ of the tumor. At first 

the tumor becomes pedunculated; then 
the pedicle is elongated until the inter- 
nal OS has been dilated. Finally, in 
favorable cases, the tumor is delivered. 
More often necrosis of the tumor sets 
in lx»fore the delivery is accomplished, 
and we have a Sloughing Fibroid. 

A pedunculated submucous fibroid, 
if of small size, is caUed a fibroid 
polyp (see Fig. 107), and is to be dis- 
tinguished from a mucous polyp, one of 
the manifestations of glandular endo- 
metritis. In all forms of fibroids, more 
especially in the submucous and the in- 
terstitial, the mucous membrane of the 
corpus uteri may show evidences of 
glandular and interstitial endometritis. 
Kelly and CuUen ("Myomata of the 
Uterus") state that the mucous membrane of the uterine ca\ity 
is generally noniial, but that cervical endometritis is relatively 
frequent when a sloughing submucous myoma exists, otherwise 
it is rare even if there Ix^ present evidences of an old inflamma- 
tory process in the ovaries and tubes. Therefore they point out 
that the siu-geon may open the uterine cavity with impunity in 
the absence of vaginal discharge and signs of tubal disease. 




Fia. 104.— Interstitial and 
Submucous Fibroids. 



SITUATION 

Fibroid tumoi-s always originate in the substance of the ut^^rine 
wall. They almost always develop in the body rather than in 
the neck of the uterus, and they are more commonly found in the 
posterior than in the anterior or lateral walls. 



FREQUENCY 

Fibroid tumors are the most prevalent of all neoplasms affecting 
the uterus. As regards their frequency among women, ma«^ 



FREQUENCY 



249 



ithors <juote Bayle (S, H. Bayle, ** Diet." on 60 vol., Parin, 1813, L 
\1I., p. 73) who i^itiivtl as long ago as 1813 that 20 jkt cent of all 
women over thirty- five years of ago have fibroids; but as other 
authors have arrived at different results (Klolj, for instance, assert- 
ing that 40 per cent of the uteri of women who die after the fiftieth 
yt*ar contain fibroid tumors), and as Bayle's opinion luu? not been 
confirmed, we may state that the exact frecjuency of tlii' t iiniurs is 
yet to be d(»termine*i. They are met with mostly dm'ing the period 
of sexual maturity, between the ages of thirty and fifty years, being 
rare before twenty and after fifty-five. Gusserow, out of 919 cases of 
fibroids, found only 15 under twenty years of age and ordy 17 over 



Left ovary •^ 



InTraligCLmefjtbus 1 1 






fOfOnf 



\ 



TX] 



I 



Fio. 105. — Diagmni Showing an Intraligamentous Fibroid. 

ty years of age. The highest {percentage, 38,8, was between the 
^t*8 of thirty and forty, and the next highest, 36J, was between 
forty and fifty. Fibroids are undoubtedly wry fri^iuent in the 
ne^ro race. The autopsy statistics of the Jolins Hopkins Hospital 
show, acconiing to K*'lly ami Cullen C'Myomata of the Uterus/' 
1909), that out of 742 autopsies on white and black w^omen, over 
twenty years of age, 20 ]wr cent had fd>roifls in their uteri, and of 
thcjse, 33.7 per cent of the black w^omen hatl uterine myomata, and 
10 [XT cent of the white women were affected in this w'ay. It is 
not yet determinetl whcHher fibroids are more common among the 



250 



DIAGNaSlS OF FIBROID TITMORS OF THE UTERUS 



single than the inamcMl. Bayl(» and other authors thought that 
they wen^, while Gussctow, Dupuytren, West, and others, hold tliat 
th(»y are not. 

ETIOLOGY 

Th(» causation of these tumors is even now unknown, although 
the probknn has been studitnJ assiduously by many not^ invei^ti- 




Fig. lOG. — Large Submucous Fibroid showing Distortion of the Uterine 

Cavity. (Kelly.) 



gators (luring the last fifty years, and many hypotheses have been 
advanced, but so far none lias been [) roved correct. An ingenious 
theory is that advances! by A. Claisse (Th^se de Paris, 1900). He 
thinks they are due to infection of the uterine mucosa; subacute 
inflammatory lesions of the mucosa, especially about the little 
blood-vessels of the muscular wall, causing proliferation of round 
cells, which are transformed into fibrous tissue. Heredity has been 
supposed to play a pai1 in the causation of fibroids; Hofmeier, 
Veit, KIeinw;icht(M-, and othei*s considering it a predisposing cause. 
It is doubtful wh(»tli(T this assumption is w(*ll founded, however, 
and we nmst regard the occurrence of fibroid tumors in members 



rorR>?E AST) DEVELOrMENT 



251 




of the Hanie fninily^a not uiicouiiuon hiip|M"iiiii)j; — as eoinridciu'cs 
rnthiT than exaiiipk^s oi hen^dity. 

Sextial irritation, siicli as mast iniiat ion oj' alTMornifil sexual 
practicet^, has 1)cqu assigmMl as a c*ausi* of niyonm by \'v\t. \\ liili* 
the chronic congpj^tjon which is due to inn hie irritation of thf 
genital organs may a^^isi the growlh of a fihniid, it is difFicnlt to 
sei* how it couM originate one. It is ijrohiilJt' that many lil>roitl.s 
of congenital origin, i>erhaps due to a fetal misplaeement of 
tissue accortling to Cohnheim*s th«*ory, but, as ah'eady statcni, 
this ha*^ not l)een proved. The tumors do not attain any con- 
siderable size until the lat(^ ehild-lji'aring [K^ricH^ therefore age 
must be considered a facttjr in tlit* etioh»g)'. 



COURSE AND DEVELOPMENT 

development of a fibmid is a slow affair, g(*nerally a matter 
years. 11. A. Kelly has eited a eas<^ whieh wa*^ under mediral 
olisi*rvation for twenty-five y(*ars lH*fort» opt'rati*»n and two velars 
after. «/* Operative Gynecology/* H»()7, \ Dl. II., p. 347.) A large 
interstitial tumor, with a uterine cavity measuring eight or nine 
iiches, became larger and sul>peritoneal and perluneulatiil so tliat 
operatitju it wa^ found atla(*hed to a sjuail uterus by a [M'diele 1 
centimeter long and 3 centimeters broad. It weiglied 59 pounds. 

I have sjx)ken of the direction of the growth in ileseribing the 
differt*nt kinds of tumors. Upon the course taken by the tumor 
ill itii growth deix^nds often its subsequent fate. For instance, 
if it gnjws subsiTous it may Ix^come pedunculated and in time 
may be separated entirely from the uterus^ receiving its nourish- 
ment through mlhesions to surrounding structures. Such easels 
are rare, but are met with occasionally. If, on the other hand, the 
tumor grows toward tlie uterine cavity, it is a|)t to I)e extruiled 
through the external os. In either cjise the blood supply to the 
tumor is interfen^il with ami there is a tendency to necrosis and 
ck»generative changes. If the tun»or remains in the sutetanee of 
the uterus, as in the ca.*^^ of an int<'i>?titial fibroid, its nourishment is 
tabHshed on a surer footing. It is possible for all tumors, ami 
small tumors especially, to remain in a r|uiescent state for an 
Tndefinite i>eriod. Bland-Sutton (** Tumours Innocent and Malig- 
nant/' -1th Edititju, 19(10. p. 1S7) calls attention to the latmt seedltmj 



252 DUGNOSIS OF FIBROID TUMORS OF THE UTERUS 

fibroids J in regard to which ho says: "If a number of uteri be ex- 
amined from women Ix^twei^n the twenty-fifth and fiftieth years by 
the simple means of sectioning them with a knife, in a large propor- 
tion of these uteri a number of small rounded fibroids, resembling 
knots in wood, will appear, their whiteness being in strong contrast 
with the redness of the surrounding muscle tissue. These discrete 
bodies, in many instances no larger than mustard seeds, are in 
histologic structure identical with the fully grown tumours." 




Fig. 107. — Pedunculated Fibroid Originating in the Cervix that has been 
Expelled into the Vagina. (After Auvad.) 

When removing fibroids by operation one can never be sure that 
all tumors have been removed; therefore, a patient can not be 
assured that the fibroids will not grow. On the other hand, 
tumors may increase rapidly in size. Soft tumors grow faster 
than hard ones, as a rule. Fibroid tumors grow during pregnancy 
and diminish in size markedly after delivery. They increase in 
size just before c^ach menstrual period and diminish after the flow 
has ceased. In many instances they lessen in size after the meno- 
pause, but not always. All these facts nmst Ix^ kept in mind when 
examining a patient at diff(»rent times to determine the relative 
bulk of a tumor. 

DEGENERATIONS 

There arc certain alterations of structure occurring in fibroids, 
the causes of which we do not know, except that sometimes they 
can be explained by thc^ presence of arteriosclerosis and a diminished 
blood supply. Degenerations in fibroids are observed frequently 
following pregnancy. An increased formation of fibrous and hya- 



DEGENERATIONS 



253 



line tissue occurs in practically all myumata and, when the process 
is extensive, necrosis of the center occiu^, with a resulting cyst 
cavity with walls of irregular outline. 

Softening of a fibroid tumor may lx» duo to several causes. 
Among iheni we may enumerate hyaline, colloid, and fatty de- 
generation. 

Hyaline degeneration was noted in 3,1 per cent of 2,274 cases 
of fibroid tumors collirted by Noble from the literature C*Gj7iecol- 
ogy and Abdominal Sui-gery,** H, A, Kelly and C. R Noble, 1907, 
p. 669). Often these tumors become progressively indurated, 
esprially after the mrriopuuse. 

Colloid or Myxomatous Degeneration. — This is characterized by 
the effusion of niueous material between the muscle bundles, the 
mucin and proliferation of round cellst in the inter-stitial tissue 
disi inguishing it from edema. Noble found myxomatous degen- 
eration in 3.4 per cent of his 2/274 cases. 

Small, hanl tumors are found at autopsies on old women, their 
pn\st»nce not ha\ing been detect^nl during life, 

Fibro-cystic Tumors. — ^Tht^se tumors residt from the breaking 
down and liquefaction of areas of degeneration in fibroids and the 
fusion of diffen^nt foci by the absorption (if the di\'iding partitions. 
The degenerated areas are separated, not by distinct walls, but by 
portions of the fibrous structure of the tumor. These tumors are 
not, as formerly thought, a separate class of timiors. 

Doleris [Archiv. de (ocrdoffie, jariv. et f^v., lS8.'i pp, 1 and 354), 
noted a proliferation of eonnective tinsue l>ecoming colloid in a 
fibroid tumor during pregnancy. After tlehver}^ it is supposed 
that the diminution in the nizc of a fibroid is due to fatty degen- 
eration. 

Calcification. — ^This is rather a rare transformation which Noble 
{he, cit,) found m 1.7 per cent of his cases. Deposits of phos- 
phate and carbonate of lime are found near the peripher)" or the 
C4?nter of the tumor and make r*itlier a bony framework — ^not true 
bone, however — or a shell. Rarely is the tumor solidifietl to 
mike the so-called ** uterine stone." Small areas of calcification 
are not uncommon. 

Fatty Degeneration. — Gusserow (** Die* Neubildungen des Ut^:*- 
nis/' 1886) ha^ callcnl attention to the fact that fatty degeneration 
of a fibroid tumor has been determined microscopically in only three 




254 



DIAGNOSIS OF FIBROID TUMORS OF THE UTERUS 



cases — ^those of Freund, A. Martin, and Brunings — where there has 
not been resulting diminution in the size of the tuinor as well. 
There is a form of fibroid tumor called lipomyonia in which a por- 
tion of the tumor is composed of fatty tissue. 

Edema. — Edema is often present in fibroids and may be con- 
sidered a beginning stage of necrosis. It most often affects the 
sul^serous tumors. 

Amyloid Degeneration. — ^A single case of amyloid degeneration 




Fig. 108. — ribroicl of the GtTvix Distending the Vagina. (After Dartigiies.) 



of a fi]:)roi(l polypus has been observed by Stratz. {Zeit. /. Geburts. 
u. ihjn.., 1889, Bd. XVII., H. 1, p. 80.) 

Suppuration. — This is the result of the infection of the tumor 
with bacteria deprived from the intestinal canal, the genital tract, 
or the blood. Prolonged pressure of a tumor on the bowel, or an 
appendix vcM-miformis adherent to the tumor, may permit easy 
pcMietration of inicroin-ganisms. Instrumental or digital invasion of 
the uterine cavity for exploration or curetting may infect a fibroid, 
espi^cially a submucous myoma. 

Gangrene. — (langrenc^ may n^sult when a tumor is undergoing 
dt^generation, or when there is toi-sion of its pedicle. Micro- 



COMFLRATrONS 



255 



organwmris nmy or may not play a part in tht* iieerobiotic process. 
The nuThatiism of the pi-ocess is obscure. Extreme torsion of a 
tunior, caui^ing stai^is of the blcxxl supply and iieemsit? or gangrene, 
18 a ran* rornplieation of fihruitl tunitu's, ZangemeiHler thought 
that the fibroid uterus when rotated showed eonnnonly (21 times 
to 3) a torsion to the right j^ide. 

Thrombosis. — Thrombosis of the IJmxl- vessels of a filiroid nmy 
oceur. It is probable that the turuor i.s tohTated in tlie Ixnly fur 
a long time after the blood J^upply is cut off Ix'fore it Ix'ooines in- 
fected, just a^ in ca^t^s of neglected extra-uterine pregnancy in the 
late months. 

Sarcomatous Degeneration.— This tJccurrt^Hl in two pi*r cent of the 
CBses collected by Noble (/oc. ciL), and Winter {Zeiis, fiir Geburts. 
uvd Gijmkol, Bd,, LVII., II. 1, 11W)6, p. 19) found sMrroma in 
4.3 |XT cent of 2.Vi ea>ies of fil>roid tiuiior in which sections were 
token J5)^stejiiaticaily from different i>arti5 of all tumor's. 



COMPLICATIONS 

Carcinoma occurs a.s an associated lesion in fibmitl tmncji-s, not 
a«f a degeneration, for w^e know that the two processes ai*e distinct 
hjHtologically, with the excr|ition of a few* cases of adenomyoma 
when^ cancer has \x^vn ilescrilMsl as s|*ringuig ihreet from tlie 
glands; within the tumor. lu n study <»r 4,880 consecutive cases 
of fibroid tumor, Nobh^ t/oc. ciL) found that cancer was present in 
2,8 f^er cent. In his jK^rsonal expi^rience with 337 fibroids, cancer 
of the corpus was prest^nt in 2.6 jx^r cent, and cancer of the cervix 
in 1.4 per cent; hence, as women not the subject of fibroiil tumor 
have cancer of the crrvix ten times to one foi- c^aneer of the corpus 
uteri, he condudrd that tliere is a eausal relation iK'twt^en fibroma 
and cancer of the lx>dy of the uterus (a<leno*carcinoma of the 
eiidonu'trium). 

Metastases.— Fibroid ti.ssue can h^ in varied and destroyeil by 
an epithe'lial growili. The most frequent comliination is occurrence 
of carcinoma of the body of the uterus coincident with fibro-myoma. 
Sfimetimes a fil)mid tunmr intrudes in its tissues glandular elements 
flerivi**! from the iluets of Miiller or Wolff, and these elmients are 
^ubjecjt to a citrcinomat us transformation. X, Btiider and G. 
I^rtlennois {BxM, Sac, Anat., lOtW, No. 8, Octobre) have shown 




109. — Large Globular Fibroid, the Lower Part Filling the OnHty of the 
PelviB, Simulalmg Pregnancy at Term. (Kelly.) 



alone were affected. Aiiiong L39 causes gathered from the litera- 
ture in addition to his own cases he found lesions of the tubes 32 
times, alterations of the ovaries alone 79 times, and tuho-ovarian 
disease 28 times. Among 70 eases observ^ed in Pozzi's clinic the 
most common lesions were catarrhal salpingitis, purulent salpin- 
gitis, hematosalpinx, and cystic degeneration of the ovarias. In 
Noble's 2,274 cases of fibroid tumor (loc, cit., p. 668), complications 
in the uterine appendages or in the pelvis existt^ in 37 per cent. 
In Pozzi's chnic lesions of the tubes and ovaries occurred in 59 
per cent of the myoma cases. 



EFFECT OF FIBROID TrMORS 



157 



In thi! anal>*sis of those ^tati8ticB it is luit to Ix* forgotten, how- 
ever, that these large percentages were among women whose 
fibroid tumors nujuiriHl .surgical treatment; they had entered the 
hof^pital for Ojieration. It is hardly fair to a^^uine that all fibroids 
■ are subject to complications to the same extent; in fact, this is an 
objt*ction to mo.st of the statistics which have to do only with 
fibroid tumors causing Bymi>toms of a severe grade. 



r 



I 



I 



EFFECT OF FIBROID TUMORS UPOH NEIGHBORING ORGANS 

The uterus, being attai*heil to the vagina, to tlie uterine liga- 
ments, and to the {>eritoneimi^ is nioiv or less liniitefl in its move- 
mt^nts. If a fibroid tumor deveIo[»s in its substanc(% the uterut^ 
may ilispiace the blailder or press tht* rectum, urethra, or ureters 
against the bony framework of the jx^lvis. In the case of a fibroid 
of the posterior uterine* wall, the cervix ma}" press on the urethra 
and cause* retention. But this is a rarity. The bladder is extremely 
tolerant to misplacement liy a tumor, IIowcvit, retention is some^ 
time^ caused in this way, ant I congestion of the vesical mucosa, 
which exists in the cas«* of fii^roids as dctiTminetl by Zukerkauill 
thniugh cystoscopie examinations (A. W'uot, Annaka de gijn. et 
d'ijbstet, 1907, 2 s.. IV., 287-310), fur'nislies a favorable soil for the 
growth of bacteria that may be introduecMj by a catheter. Injmy 
of the ureters an<l kidneys from pressure on tlie uret<*rs is much 
more frequent than thought formerly. Knox has refKjrte^J a series 
of eases of compression of the ureters observed during operation 
on fibroids at the Johns Hopkins Hospitak Of the different vari- 
eties intraligamentous growths and tumors developing from tlie 
errvix are most apt to compress the ureters and also to tlisplaeo 
them upward. 

It is difficult to say even ap[iroximateIy just wliat is tht* fn*- 
([uency of R^nal iliseast* because of ureteral comijression by fibrtJid 
tumors, J. C. Web«4er fomid n»nal complications due to fibroids 
in 30 per cent of lOt) cASl^'*— on the other hand, Ilaidtain in 120 
caf«es had never met renal coni|>lications, C*uI!ingvvoi1h met liydro- 
lirphnisis due to compression in 2 out <jf lt)0 casi/s: Sarwey, 1 in 
430 eaBPit: Knox, 3 in 4(X); A. \imoi points out that the rom- 
prcsdion of tlie ureter is probably intennittcnt, due to the motion 

17 




258 DIAGNOSIS OF FIBROID TUMORS OF THE UTERUS 

of the fibroid; therefore symptoms due to the compression are not 
present with any definite regularity. 

Interference with defecation due to pressing on the rectum by 
a fibroid tumor is a common complication. 

Tumors situated low cause the greatest degree of interference 
with the enlargement of the uterus during pregnancy and with 
deliver}'. Fibroids, then, are a cause of abortion. Lefour (Th^se 
d*agr6g. de Paris, 1880), out of 307 cases of pregnancy compli- 
cated by myomata, noted 39 abortions (12.7 per cent), the mother 
dying in 14 cases. Nauss (These de Halle, 1882), out of 241 
castas, found that al)ortion took place in 47, or 15 per cent. The 
tumors situated low in the pelvis obstruct delivery; if situated 
elsewhere in the substance of the uterus they generally interfere 
with involution and are the cause of post-partum hemorrhages. 
Although the presence of a fibroid is by no means a bar to the 
occurrence of pregnancy, it is a frequent cause of sterility. OL^ 
hausen gathered the statistics of nine difi'erent observers, including 
Scanzoni, von Winckel, Schroeder, and Hofmeier, and found that 
out of 1,731 married women with fibroid tumors 520, or 30 per cent, 
were sterile. He considers this figure too high, however, because 
many women with fibroids come under a physician's observation 
only because of sterility, and those who become pregnant often do 
not consult a physician at all. 

EFFECT ON DISTANT ORGANS AND ON THE SYSTEM 

Anemia from prolonged and repeated hemorrhages is one of the 
most connnon results of fibroid tumors. The hemoglobin may be 
reduc(Ml as low as thirty per cent or even less and the red cells to 
1,()0(),0()0. The affection is a serious one and diflftcult to correct 
ofti^n, even after the drain of blood has 'been stopped. Acute 
hemorrhage in fibroid cases seldom proves fatal, but the continued 
loss of blood produces a condition of lowered vitality, and a dis- 
position to thrombosis, emlx)lism, and phlebitis that counter- 
indicates in many cases an operation for the removal of a tumor. 
Many autliors state that the hemoglobin should be at least fifty 
per cc^nt before^ a hysterectomy is undertaken. Kelly and CuUen 
howx'vcM', {loc. cit.y pp. A'hi and 4r)4), report twenty-two cases of 
operation for the removal of myomata in w^hich the hemoglobin was 



RELATION OF FIBROID TUMORS TO HEART DISEASE 259 

forty per cent or lesi^, with a moi-tality of thj-ef^ case8. It ofteo hap- 
pens that several years elapse before a profouiitUy anemic patient 
regains goocl health after the cause of the loss of blood has been 
removed* 



RELATION OF FIBROIB TUMORS TO HEART DISEASE 



m 



Tlie frefiiicney of eardiao palpitation in fibroid tumors has been 
refcrreil to by me. {Amer. Jour. Obdei., Vol, XXIX., No, 3, 1894.) 
The qrmptom appears to be quite mdepenclent of actual cardiac 
di8i:*ase, there being no e\i(lences of enlargement of the heart or 
of adventitious murmurs. It is possible that ]ialpitation may Ix: 
due to anemia, in which event one t^xjii'cts to find heniir nmrnuu's, 
and some influence must Ije a^ssigned to the menopause in patients 
who are in tins time of life. (See Chapter XXIX., page 613,) 
Tlie exact relation of these tumors to heart disc^a*^* is not known. 
Certain degenerative changes in the heart and in the blocMl- vessels, 

eh as bro\nj atrophy, fatty degeneration, fatty infiltration of the 
eart muscle, also chronic endocarditis^ and aiteriosclerosis of the 
arteries have Ix^'n notetl by stutlents of this tjuestion, notably by 
Hofmeier, Fenwick,Strassnmn and Lc^hniann, Boldt, Pellanda, Win- 
ter, and Heck, as quoted by Nol>ie (/or. cit., p. 671). Winter found 
the heart piM-feetly normal m 60 per cent of 266 easels examinetl 
with reference to this point; vaKnjlar disease was found in but I 
per cent, and dilatation and hypertrophy in but 6 per cent, the 
oxaminations being made in every case by a specialist in internal 
inedirine. 

It is difficult to umlt*rstand how lesions of the heart can 1k' 
causi^l by tumors. I thuik w^' may agree witli Winter that, ui 
the present state of om* knowledgi\» w^e must attribute alm*)st all 
of the cardiac symptoms in cases of fibroid tumors to anemia, anti 

nfieciuent derangement of the nervous system. It is well to re- 
member, however, that hiart dis*'a^ not infrefjuently accompanies 
fibroids, although not necessarily in a causal relation. 



260 DIAGNOSIS OF FIBROID TUMORS OF THE UTERUS 



DANGEROUS TO LIFE 

Fibroid tumors may be a direct menace to life. Pellanda (C. 
Pellanda, *'La Mort par Fibromyomes Ut^rins/' Paris, 1905), in a 
study of 171 cases of death from fibromyomata without operation, 
states that in 6.4 jkt cent of the fatal cases death was due to 
hemorrhag(\ 

Acute alxlominal emergencies due to torsion and infection of a 
tumor are by no means unknown. Rupture of the uterus, due to 
fibroids ol^structing lalx)r, has occurrtHl. As a rule, how^ever, 
these tumors endanger life indirectly through their degenerations 
and complications, through interferc^nce with the function of other 
organs, and by their effect on the general health — ^aneniia and its 
consequences. 

SYMPTOMS 

Th(* symptoms of fibroid tumors are hemorrhage, anemia, pain, 
and leucorrhea, also constipation, freciuency of micturition, ret(Mi- 
tion of urine, and dysuria; the last four being the result of pres- 
sure on rectum, ureters, un^thra, or bladder. 

Hemorrhage. — Hemorrhage may be of the type of menorrhagia 
or of metrorrhagia, more often the* former. It is a sjmiptom nu^t 
with in the submucous tumoi-s, occasionally in the interstitial, and 
not at all in the subserous. As most fibroids are multiple it is 
not always easy to say which form pnnlominates in any giv(*n 
case. TIic submucous varieties cause hemorrhage by enlarging 
the surface of tlie (Midometrium, the total number of square inches 
being increased many times in tlu^ case of large tumors. 

Diapcdcsis of hmI blood cc^lls through the walls of the capillaries 
of th(* endometrium takes |)lace to a greater extent the larg(T the 
surface involved, but venous congestion caused by the prc^^ure 
of the tumor on the thin-walled veins is supposeil to be at the root 
of the mechanism of heniorrhag(^ in fibroid tumors; the arteries, 
with th("ir thicker, elastic walls, being able to withstand better the 
|)n»ssure. The (lowing may be only slightly increased over normal 
or it may amount to an excessive luMiiorrhage requiring active 
treatment. The size of the tumor bears no relation to the amount 
of the (low, the small tumors often having the greatest flowing. 



SYMPTOMS 



2(il 



It fe a curioas fact tfmt sonir womi'H witli filjroiil^ flow more wliiii 
they are lying down tliati tht'V do wlnii iijj iintl about; tlieirfun* 



tl 



\v trt*atmcnt in ^iit'ii casi*s is not rrst m Ixii. Uiis iK'ciilianty 
shoiihl tie looked for in getting the history. An active acute 
lietnorrhagc i« generally not po serious in its effect-s on the systeni 
m a lesser liloeiling lasting ovei* months and yeaiv. 

Anemia* — Anemia t^xists so fre(|ueiitly in film ml tumors that tho 
jihysician should lx» on tlie lookout for a i)ale fa<*e, lips without 
Riucu color, eyes? a pearly white, muscles rather flabby, pul.se 
bounding, hut soft and compressible, with intTcascHl rapidity on 
the sliglitest excitement. Besides palpitation a feeling of faint- 
nc*?^ aiiii bn^athlessness and languor accompanies anemia. In some 
cusi»j< tliere is swelling of the ankles. Th(* red hUnMl cells may fall 
to one-fifth or less of the normal nnmlxT (1,(M)(),(MM) per cubic 
niillinieter), and the hemoglobin to thirty f>er ci-nt. lieotic heart 
munuurs are asually piTsent. 

Pain. — Pain may or may not be present in fibroid tumors, and 
when it does wcur is varial>le in amount. It is either rc^feiTed to 
the ut<*njs or to othtT organs when doe to pressure on surround- 
ing stnictures. It assumes several forrns, occuiring as a diilb con- 
stant i»ain situatetl in one or lM»th groins or across the alxlomf*n, 
as a bt»aring-down pain, or as a backache, and these ^^arieties may 
exiM si*parately or conjointly. It may be referretl to the thighs or 
the leg^ in consequence of the pn^ssure of the tumor on the sacral 
plexus of nerves. Pressure on a ureter may cause {>ain, but the 
n*ctmn and l>ladder are generally tolerant of jiressmv s<j far as pain 
is concerned, their disturbance when [jresseil upon showing itself 
in derangement of function. Dysmi^norrhea occius in aliout twenty 
per cent of the cas<*s of fibroid tumors^ the cramiJ-likf* j>ain Imng 
often sincere. It must b*^ rememlxTeil, however, that an uncom- 
plicated fibroi<l raivly give* rise to much pain, and therefore tlie 
prtMcnce of pain, especially if severe, indicates an inHammatoiy 
complication^ such as salpingitis or atlhesions. A rapidly grow- 
ing tmnor is apt- to cause pain which Is referred to the utenis. 
Expulsive f^ains an* found whim a subnmcous tumor lx*conies 
peclunculated and can tie extnKknl either in part or wholly at the 
extemal <^s, Kelly and Cullen found tJiat tunjors of moderate siasc 
eausi*d the most pain. 

Leticorrbea.— A vaginal tlischarge is rare in £broids except in 



262 DIAGNOSIS OF FIBROID TUMORS OF THE UTERUS 

the submucous variety. In this form it is common as a white 
discharge, and if the tumor is necrotic the discharge is muddy, 
watery, and malo<.lorous. A profuse watery discharge associated 
with fibroids should always excite suspicion of cancer. 

Symptoms of Adenomyoma. — ^According to Cullen this variety 
of myoma is most prevalent between the thirtieth and sixtieth 
years and does not tend to cause sterility. Lengthened menstrual 
periods are the first symptoms and the flowing gradually assumes 
the proportion of hemorrhages. There is pain with the period 
that is referred to the uterus; it may be grinding in character. 
There is no intermenstrual vaginal discharge and microscopical 
examination of scrapings shows the uterine mucosa to be normal. 



DIAGNOSIS AND DIFFERENTIAL DIAGNOSIS 

The diagnosis of large fibroid tumors is a comparatively easy 
matter, but the diagnosis of small ones is often difiicult. The 
symptoms are not of much assistance, except that painful menstru- 
ation beconiing profuse and protracted, and a history of sterility 
or early niiscarriag(\<, are suggestive of fibroids. The chief reliance 
is the bimanual palpation; and the passage of the uterine sound is 
most us(»ful. The first point to determine is the relation of the 
tumor mass to the body of tlu* uterus. 

Subserous Fibroid Tumors. — If the tumor is a single mass bi- 
manual palpation shows that it is connected with the uterus. 
To determine this point place the tip of the forefinger in the vagina 
on the cervix. On mo\nng the tumor with the other hand on the 
aUlomen, note whetluT the cervix moves at the same time. Out- 
line the growih as exactly as the laxity and thinness of the ab- 
dominal walls will permit. In some cases of small-sized tumors in 
woiiicu with thin parietes, it is possible to map out the ovaries, 
and an attempt should Ix' made to do this in every case. If the 
tumor is pedunculateil it nuist Ix' diflferentiated from an ovarian 
ci/fit. This is (lone by detecthig fluctuation in a cyst. Making 
firm pressun^ against the tumor with the finger in the vagina, taps 
with the linger of the hand on the abdomen are transmitted to 
th(^ finger in the vagina as waves. The pedicle of a pedunculated 
myoma may be palpated by drawing down the cervix with a 



DIAGNOSLS AND DIFFERENTIAL DIAGNaSIS 263 

VTil^IIatii, which ia pa*^sed to an asj^i^taiit to hold while the bi- 
manual recto-alxlomina! touch in practised. (See Fig. 126, page 
301.) If the content.^ of the f*yst are thiek and semisolid, avS in the 
case of dennoid oyst?^, the fluid waves will be absent. Some ova- 
nan cysts are as hard as some fibroids, especially soft filiroids. 
As a rule the fibroids are imiltiplc and thci*e is more than one 
nodide to be reckoned with; not only that, !>ut the nodules are 
usually of a stony hardneas. If the fibroid tumor or tumors are 
large enough to distend the aklonien the uterus is drawn up in the 
pelvis. This upward excursion of the uterus does not take place in 
the ease of an ovarian turmor. 

Fibroma of the ovary has b*en mistaken for a pedunculated 
suljt^erous fibroid. Here only an alxiominal operation can clear up 
the diagnosis. The sound shouli! Ix* pa-^s<xl. Fibroids are so often 
multiple that a lengthent?d canal may indicate a submucous or an 
interHtitial fibroid and therefore indirectly point to a subserous 
tumor. Before passing the sound observe strict antiseptic precau- 
tions and always uiquire as to the date of the la.^t nienstnia- 

ti0D» 

Pelmc injlammaiory exuviate may complicate a fibroid tumor, but 
\b seMom mistaken for it. The mass in inflammation is brawny and 
fills in the chinks of the i>elvis. There is a histor}' of fever, even 
if it is not present at the time, as shown by the thermometer. 

Cancer of the pelvis, originating in the uterus or ovaries, may be 
nxistaken for fibroid tumor, but is difTorentiattHl by the fixity of 
the infiltration, and the lat'k of definite outline of the tumon 

Ascites is occasionally present in large tumors. Change of posi- 
tion of the patient (*hanges the situation of the fluid, which is 
mapped out by its flatness to percussion. 

The contour of the alxlomen in the ca*^ of large fibroids is dome- 
shapeil if the fibroid is globular and single, nodular if nmltiple. 
The tumor stands out sharply on all sides when seen in profile, 
tSee Fig. 103,) Ascites, if it is jiresi^'nt in excess, modifies the contour. 

Intraligamentous Fibroid Tumors. — ^An intrahgamentous fibroid 
\» situated at one side of the uterus, the sound showing the situa- 
tion of the latter if it can not be palpatcn:!. This sort of tumor is 
low" in the pelvis, often it can be* felt projecting into the vagina. 
Its mobility is limitetl because of its attachments and its situation. 

iDterstitiAl Fibroid Tumors. — The uterine canal is conunonly 



204 DIAGNaSIS OF FIBROID TUMORS OF THE UTERUS 

lengthcne<l in cases of interstitial fibroids, and hemorrhage is likely 
to occur in these tuinoi-s. In this variety the enlargement of the 
uterus may Ix* symmetrical, or it may be asymmetrical. In the lat- 
ter, the diagnosis is easier to make; in the former, one must rule 
out pregnancy. To do this it is important to get the history most 
carefully, having regard to amenorrhea and nausea. The elastic 
feel of the pregnant uterus is to l^e sought for, also the softening of 
the cer\'ix and the bulging of the anterior segment early in preg- 
nancy and ballottement later. (See Chapter XXII., p. 423.) 
Breast changes are to be looktnl for, and if the tumor is large an 
attempt should be made to auscult the fetal heart sounds. An- 
other examination a month later will confirm a diagnosis of preg- 
nancy. 

A fibroid rarely Ix'comes cystic before it has attained the size of 
a three months' pregnancy; therefore, an elastic tumor of less 
than this size is probably not a fibroid. The sound is not to be 
passed if there is the slightest suspicion of pregnancy. Examina- 
tion under ether is advisable if the abdominal walls are tense or 
the conditions for examination are not entirely satisfactor5\ 

Sarcoma may develop in a fibroid. In this event the tumor has 
grown rapidly. Only ojxTation makes a positive diagnosis of sar- 
coma. 

Submucous Fibroid Tumors. — A historj' of hemorrhage is present 
in almost all submucous fibroids. Here the diagnosis is established 
by the sound and, if necessary, by digital exploration of the uterine 
cavity. Bimanual palpation determines an increase in size of the 
uterus. This is true even in the case of small growths. Tlie 
sound shows enlargement and distortion of the uterine cavity. 
If the tumor is at the fundus notliing but digital exploration will 
settle the question wh(*ther it is sessile or pcnluncidated. Some- 
thing may be learned often by the tactile sense transmitted through 
the exi)loring sound. To make a digital exploration of the uterine 
ca\ity th(» cervix is to lx» dilated by a series of dilators: the Hanks, 
followed by the Wathen or by large Simon dilators, plenty of tinu^ 
Ixnng taken so that rupture may not occiu*. In cases of hard, 
resistant ccTvices it is Ix^st to adopt the method of incision of the 
antcTior wall of the cervix descrilxMl in Chapter VII., page 94, 
n^pairing the cervux by suture after the exploration is finished. A 
sessile submucous fibroid of the fundus ut<?ri may be mistaken for 



DIAGNOSIS AM) DIFFERENTIAL DIACINCW^IS 20.") 

lulrnoiim or adcno-carciiioinii. A piece rcinovcil and sul)iiiitt('(l 
to iiiicroscopic cxainiiiatioii is tlic* only in(»ans of <Hstin<^uisliing 
the two. A iHMluiicuIat(Ml tumor presenting at the external os may 
Ik' mistaken for inversion an<l, if sloughing, for earner of the cervix. 
It is distinguished from caneer by learning that the sound may 
Ik* mad(» to .^\v(»(*p entirely around th(» tumor, thus making sure 
that theeerv'ix itself is not th(» seat of the disease; and from inver- 
sion l)y noting, l)y bimanual reeto-alKlominal touch und(T ether, 
that the fun<lus uteri is in its normal situation. An invei1(Ml 
uterus is usually very sensitive to touch, although not invariably so. 
Cancer of the body of the uterus and chorioejyithelimna are to be 
exclude*! by the (examination of tissue remove<l from the utcTine. 
cavity l)y cun^tting or l)y <ligital exploration, and, in the case of 
chorioej)ith(»lioma, l)y the history of a j)revious lal>or, alx)rtion, 
or hydatidiform mole having occurred within a few weeks. 



CHAPTER XVI 

THE DIAGNOSIS OF MALIGNANT DISEASES OF THE 

UTERUS 

Cancer, Sarcoina, and Malignant Chcjrioepiihdioma 

Cancer of the uterus, p. 266: Definition, p. 266. Varieties, p. 266. 
Diagnosis of cancer of uterus in general, p. 270. Diagnosis of cancer of the 
cervix, p. 271; Differential diagnosis of cancer of the cervix, p. 272. 
Diagnosis of adeno-carcinoma of the cervical canal, p. 275; Differential 
diagnosis of the adeno-carcinoma of the cervical canal, p. 276. Diagnosis 
of cancer of the body of the uterus, p. 276; Differential diagnosis of 
cancer of the body of the uterus, p. 277. 

Sarcoma of the uterus, p. 278: Frequency and definition, p. 278. 
Varieties, p. 279. 

Malignant cliorioej)ithelioma, p. 280: Definition, macroscopic and mi- 
croscopic apjiearances, j). 280. Course of the disease, p. 281. Ectopic 
malignant chorioepithelioma, p. 282. Diagnosis, p. 283. 



THE DIAGNOSIS OF CANCER OF THE UTERUS 

By cancc^r of the uterus we understand a malignant new growth 
the essential eh^nients of which consist of epithelial cells having a 
charact(*ristic arrangement. The cancer cells may proliferate and 
(Hrectly invacU^ the surrounding tissues or they may be transported 
by the lymphatics to distant sites and there proliferate and form 
metastatic growths. 

Varieties 

The mu(H)us membrane^ of th(» uterus may be divided into three 
types: (1) That covi^ring th(» vaginal portion of the cervix, extend- 
ing from th(^ vaginal vault to the external os, and composed of 
s(iuamous-celIed (^pithehum. (2) That lining the cervical canal 
from the (external os to the internal os, and composed of high 
cylindrical (epithelial cells; and (3) That lining the uterine cavity 
proptT from the internal os to the fundus, and composed of low 

26() 



CANCER C»F THE UTERU8 



267 



indrieal or culx)itla! epithelial cells. Cancer of f lie uterus al- 
ways originates in the mueoas ineiiibraiie, anil the type of cancer 
is detennined by the character of the cells of the mucous mem- 
brane in which it originates. 

We have then three kinds of cancer of the uterus; 
1, Squamous-celled cancer of the cervix, 
Adenocarcinoma of the cervical canal. 
Adeno-i!areinoma of the body of the uterus. 



FlO* 110.— Billy Slsge of Squamous-c*41ed Cancer of tlie Cem^. The Cauli- 
flower Maas hu5 been Curetted away, (CuUen.) 



Very rarcJy there is pn^sent a Bquamous-celletl cancer of the 
body of t he uteras. 

1. Squanmus-celled cancer of the cervix begins at or near the Junc- 
tion of the cervical and vaginal mucous membranes at the external 
06. ClinicallVi three tj^x^s are recognized: («) The everting or 
cauliflower gro\\1h, in which there is marker 1 proliferation of the 

■ cancer, the growth Bpremling to and invoKing by rlirect extension 
the vault of the vagina, (h) The mflltrating type, in which the 
external contour of the cervix may remain nonnal, the growth 
extending internally deep int^ the wall of the cer\ix. (c) The 

■ ulocrative type, in which ulceration with loss of cervical tissue takes 
place early and proceeds until the entire cervix is eroded. 




268 DUGX06IS OF M.VLir..VANT DLHE.%SE8 OF THE rTEftrS 

TJjo i4<|tianioij29-rpiJeil tyj» irf imnrt*r of the cf*rvix is URtnIIy 
impiii growth and it mon tti\*oKiiis the sumrnniGn^ tissues 
QrgBii9 — the UaddcT, the unFters, aikI mrlum. Hie l\^it>h gland 
of the pannnetritmi and t>ie iliac ^ands receive the cancer hyl 
means of the lymph channels and theoidelTBS take up the disease.! 

Mirroecopieally the squamaiis-cdled t>^ begins as an hyper- 
tnipliy of the i)a\-ement sqtuunott? epitbeltum of the eer%ix. The! 
celk theni^^vtis hj^pertrophy an^l have large round or oval verfc-J 
ular nuclei with many niitodc figare& These celts invaiie tl 



V 



-^- 



Fig. 111.-^ Very early Adeoo-Carcinoma of the Cervical CoqaL (Cullcn > 

cervical tissue in all directions and without any tjijical arrangf^ 
ment. 

2. Adeno-careirumta of the cervical canal originates in the high 
cylindrical epithelial cell?^ lining the cer\'ical canal and the glands 
of the cervical canal This t\T>e of cancer of the cervix sproadi? 
perhai>s le.ss ra|)id]y than the sciuamous-eelletl variety, although 
necrosis takes place rather eaiiy. The squamons-celled \^ety 
i^^dom spn*a<Ls bc*yond the level of the internal os. but the adeno- 
carcinoma fre<4uerjtly reaches to the fundus. The cervix may be 
reduced to a mere shell by the ntH*rop?is of the latter form of cancer 
and yet the external contour of the cerroc n^mains unchanged. 
Metastaas to the surrounding organs, the bladder and rectum, 



4 






taki»s place usually by dirwl extension of the grovith. TUv iliae 
glands an* involved j^ornetinjes early and sometimes late, as is the 
Cai^ with the .^f|uanious-e(4Ied variety, 

Mieroseopi rally adini(>(*nrrint)ma of the eemx is recognized 
as a proliferation of the eylindrieal cells of the cervical niucoiis 
membrane, thest* cells preservdng their alveolar or glandular ar- 
rangement, Tliere is distinct loss or erowrling out of the inter- 
glandular stroma, the proliferathig alveoli lying close to one anothi/r. 

3, Adeno-cartincffm of the body of the uterus originates in the 
low columnar epithelium linhig the uterine canity and the giant Is 



f^wfisi/i,/^ 




^la. 112,— Eftriy Adimo-Cttrcinonm of the Body of tlif rteriis. iX'»illuji.) 

of the endonietriuni. Ir ustiully starts at the fundus or in one 
eonm as a eircuniserilK'il area of [jroliferation of the endometrhirrL 
From tliis jxjtnt it may spread until it involves the entire uttTine 
canity. The grouih may proliferate, fonning actual outgrowths 
of endometrium into the uterine cavity, as well as invade tlu* 
uterine nuiseular wall. The growth may ulcerate its way through 
the uti'rine wall and ap|M*ar in thr jKTitoneul cavity ami fonn 
pcritonc^al metastascsft, Tliis is generally a lati* j»rT>ee8s of a long- 
existing cancer. The nrdinary b»»nign uti^rine poly|), lunng eoverf**! 
by endometrium^ may become carcinomatous* Adenoi^areinotna 




270 DIAGNOSIS OF MALIGNANT DISEASES OF THE UTERUS 

• 
of the body seldom extends beyond the mternal os, although adeno- 
carcinoma of the body and cervix may coexist. 

Glandular metastasis from this form of cancer is late. 

Microscopically adeno-carcinoma of the body is recognized by 
the proliferation of the low cylindrical cells of the endometrium 
of the fundus, these cells preserving their glandular arrangement 
with distinct loss of interglandular stroma. The cells lining the 
new glands are from two to four layers deep or possibly entirely 
fill the alveolus. 

Diagnosis of Chancer of the Uterus in General 

It is important to keep in mind that cancer is always a local 
disease in the beginning and that prompt removal of the diseased 
tissues effects a permanent cure; therefore early diagnosis is espe- 
cially important. A failure to make a correct diagnosis is followed 
surely by the death of the patient in from six months to a year 
and a half. Late operations, except in the case of cancer of the 
body, are of value only in prolonging life a few months or a year 
or two, and in lessening suffering. The view commonly held by 
the laity, and, sad to relate, by too many of the medical profession, 
that cancer is an incurable divSease is not true, provided that it 
(;an be nn-ognized and removed before it has gained a good head- 
way. 

It apj>ears that progr(\ss is being made in getting patients to 
submit to examination at earlier periods of the disease. G. Win- 
ter's works in spreading a propaganda, both among the physicians 
and tli(i laity, in East Prussia, is most encouraging (Zentralblattfur 
(iynOkologie, 1904, No. 14, p. 441). It is a fact, however, that at 
th(* ])resent time a large proportion of the sufferers from this dread 
disease are permitted to get into an absolutely hopeless state, then 
to go through the awful months of suffering until a lingering death 
releases tlu^ni. 

The symptoms of uterine cancer are by no means pathognomonic; 
they are sugg(\stive and are as follows: Bleeding, particularly in 
women who have passed the menopause; and hemorrhage or a 
show of blood [ifter coitus, also a })ei*sistent or recurring sero- 
sanguinoleut vaginal discharge. Neither of these is a symptom 
of the normal menopause, as has been maintained in the past. The 



CANCER OF THE UTERUS 271 

menopause ha^ no local symptoms if t\w uterine organs are normal. 
Iilc(»tling or a vaginal discharge occurring at the time of change of 
life shouifl lead at once to a vaginal examination to determine the 
cause. Pain and cachexia arc sympttmis of the advaneecl, hope- 
le.*^ stages of the disease, only at tliis time one does not have to be 
a physician to make a diagno^i^. Although the disease occurs 
most commonly in women wlio are Iwtween the fortieth and fiftieth 
years it may occur at any ag(* Ix^lween eight and seventy-six. 

Clinically, heredity seems to play a r61e» though this has been 
disputeil. 

The ilisc^Ase is relatively rare in the colored race. 

It is more frequent among women who have \jon\e cliildren tlian 
in nulliparae. 

The diagnosis varies with the progrcvss of the flisease, an<l the 
variety of cancer present; the early stages, while the normal tissues 
are being replaced by cancer cells, show only a slight local thicken- 
ing or prohferation ; the later stages, when tlie tissues are l>reakiiig 
down and degenerating, show ulceration, bleeiling» and detritus 
with foul odor. 

As has been pointed out in describing the different forms whicli 
cancer assumes, the disease advances in diffenmt manners and at 
different rates of Sjx^ed in irKlividunl cases. It may progress to a 
fatal termination in a year; on the other hand, I have had a patient 
who had the erosion t\^>e of cancer of the cervix where there was 
every indication that the dis(*ase had existfHl for twenty years. 
The tissues may be brittle and easily ilisintegrating, or tough and 
liard. The tissues most commonly invaded Ijy the different kinds 
of cancer have been noted, therefore in making a diagnosis the 
routes of extension of the disease must U^ taken into account. 
We employ both touch and sight in making a diagnosis, as well 
M microscopic examination of tissues removed, 

DiAGXDsis OF Cancer of the Cervix 

This, of all forms of uterine cancer, is the easiest of diagnosis 
because the lesions can b(» dr-tected by both touch aiul sight. 

(a) The catdiflmver growth is the simplest, growing as it does as 
a polyp-like mass j)rojecting from the cerv^ix into the vagina. In 
tba early stages tliis appears as an indurated, reddened area raised 




272 DIAGXOSIS OF MALIGXAXT DISEASES OF THE UTERUS 

alx)V(» the surrounding mucous membrane. In its later progress 
one exjxH'ts to find a larg(T tumor, reddish-gray in color, with 
softened, disintegrattnl tissue*. The sound i)erforates it with ease, 
and any manij:)ulation causes lu^morrhage. 

(6) If the injiltratimj si^rt is present the tissues are indurated and 
the contour of th(» cemx may Ik» altered or not. If the vaginal 
mucous membrani* overlying the growth is intact the diagnosis 
is difficult. In all suspicious cases a wcnlge-shaixnl piece of tissue 
should be* removed and submitted to the pathologist for micro- 
scopic examination. 

(r) TJw ulcerating variety is distinguished by an ulcer of exca- 
vating tendency. There is nuich loss of substance; the edg(^ of 
the ulcer are rough and irn^gular: the ba.se is necrotic; the under- 
lying tissu(\<! are hard to the fe(»l. If portions of the <leeper parts 
of th(» edge of an ulcer cmmble on pressure by the finger or soun<l 
the condition is suspicious of cancer: also, if the edge of the uIcit 
has a porky consistency an<l is of a yellowish-gray color. In all 
doubtful cases a piece* of tissue must Ix* removed for microscopic 
examination. To do this fix th(* cervix with a double tenaculum 
just outside the diseased area and let an assistant hold the tenacu- 
lum. If the cervix proves to he s(»nsitive inject into the sound 
tissue surrounding the diseascHl ar(»a, in several places, a few minims 
of twf)-per-cent steriK* solution of cocaine with a hy]X)demiic 
syringe. Wait five minutes. With a single tenaculum and a 
scalpel or scissors cut out a good-sized piece of the diseased tissue 
in th(» shape of a wc^dge. Be prepareil to place a catgut stitch 
with a curved ncM'dlc* should there be much bleeding. Often an 
ap])li('ation of tincture of ioduie and carlx)lic acid followed by a 
dry tampon will hr sufficient to stop all bleeding. The patient 
shouM not be dismisscHl until it is known that the bleeding has 
been controllcMJ. 

Dijf'crchtial Diagnosis of Cancer of the Cervix 

(a) Cauliflower Form. — The cauh\Hoirer form of cancer of the 
cervix nnist he (lifTcrcntinted from: 

(1) Follicular hypcrtropliic polyp. 

(2) Mucous polyj). 

(3) Paj)illary tuberculosis. . 



CANCER OF THE UTERUS 



273 



I 



(4) Myoma of the cervix. 

(5) Condylomata acuminata, 

(1) TUq follicHlar hi/itertrtjphies of the cemx prormetMlisciTto 
tiimon?, in some cases similar to polypi. They are soft, of a retl 
color, and siiow the rounded, yellow, shot-like, dilated Nabothian 
follicles in their substance, the contlition Ix'ing not imlike that in 
the tonsiL The follicles may b<' seen and felt also in tlie surround- 
ing normal mucous membrane uf the nT\ix. There is lacking the 
crumbling consistency, the sharp edges, and the imhiraied Ijase 
of the cauliflower cancer. The microscope ml! confirm the diag- 
nosis. 

(2) Mucous polypi, especially if multii>le and having a lumpy 
apix*arance, may be* niistaken for cancer. Polypi are covefed 
ever>n\'herc with mucous meml>rane, they are soft, and the sound 
will detect the position and size and sliai>e of their iK^dicles. 

(3) Papillary tuberculosis^ although relatively rare, may simulate 
closely polyp<}id earcincjma in its early stages. The external 08 
may I:k* surromiiletl by a papillary excrescence. It is jxjssible in 
favorable causes to iletermine the presence of the little glassy tubi^r- 
cles the size of a millet seed lying in the greasy, chee^ substanci* 
characteristic of hroken-dowTi tulMTculous tissue. In tuberculous 
diseases of the cervix the ulceratttl form is more common than the 
papillary. The diagnosis must be made by the microscope*, 

(4) Myoma of the cervix is rare. A cervical myoma is covercfl 
with a smooth mucous nif^mbrane, it disintegrates by ortUnary 
gangrc^ne, and has a firm and not a cmmbly consistency, 

(5) PoirUed condylomata may simulate papillary cancer, esjiecially 
during pregnancy. They form a circumscrilxHl tumor of irregular 
mirfat*e; but they liave no infiltrated base and no real ulceration, 
only a papillary surface with thick efiitheliurn. They are of a 
redflish-white color. As a rule they occur in more than one situa- 
tion at th*' same time, i.e.y on thr^ wall of the vagina or on the vulva, 

(7>) tn^tratiag Cancer. — Infiltrating cancer is confuscHl most. oftc»n 
with inflammatory diseases of the cervix occurring in connection 
with tears, especially when the tissues are indurate<l and ncwlular, 
as ihvy often are. As a nile thi^ inflammator>' process involves 
the entirt* cervix, the consistency is not so hard as in cancer, and 
the external mucous membrane is not involved. If the cervix is 
riddled with disciused Nalx>thian follicles the similarity of the two 
IS 



1 




274 DL4GN0eiS OF MALIGXANT DISEASES OF THE UTERUS 

con^iitions is often great. But here the cancer is limited, whereas 
the inflanimator}' affection is universaL In all cases a piece of 
tissue should be removeii for examination. 

(c) Ulcerating Form. — ^The ulcerating form of carcinoma must be 
differentiatf**! from: 

1. Erosion. 

2. Simple ulcer: as in prolapse. 

3. Tuberculous ulcer. 

4. Chancroid^. 

5. SjTDhilitic ulcer. 

1. If there is ver>' Uttle infiltration and induration a cancerous 
ulceration may simulate a simple erosion y especially in those cases 
where the erosion has a tliick, roughened surface. The character- 
istics of the mahgnant ulceration are to be borne in mind. Ako, 
the erosion as s<i*n through the speculum presents a bright red, 
shining apjx^aranco, while the cancerous ulceration shows loss of 
substance and a dull red or yellowish-gray color. 

The erosion has no sharp edge, but shows a gradual transition 
of the pavement ej)ithelium of the normal mucous membrane to 
the erosion by a bonier of irregular outline, and there are apt to 
bc» islands of normal mucous membrane in the erosion. If then? 
is infection of the en)sion, scar formation results. In doubtful 
cases thf* iiiicroscojx^ must Idc brought in. 

(2) Simple Vlcer.s. — Th(*se occiu* in prolapse; they are generally 
not situatfMJ at the external os, while the carcinomatous ulcers are 
more apt to Ix' in that situation. They are apt to have a light 
yellow l)asc and show cicatrization about the peripherj', and there 
are islands of mucous membrane in the central portions. After 
the prolapsed uterus has been replaced for a day, all traces 
of infiltration of the tissues under such ulcers disappear and 
evidence of repair at the edges can be seen. As a rule there 
is little or no thickening of the tissues under these ulcers. This 
is the case also with ulcers caused by an ill-fitting pessary. They 
heal readily. 

(3j Tuhercukms Ulcer. — This, although rare, is very similar to 
carcinomatous ulcer. Both an* generally situated around the 
external os; the base of the tulx^rculous ulcer is yellow in color, 
no< hilar but not infiltrated. Yellow, miUary tubercles may be 
seen in the mucous membrane in the neighborhood of the ulcer. 



CANCER OF THE UTERUS 



275 



Th 
■ am 



There fs apt to be present also tuberciilosiH of the entiometriiim 
and of the tubes. The niieroscope settles the diagno^. 

(4) Chancroids are generally small in .size and multi|>le; tlieir 
-se has a tliphtheritie^ gra>ish appearance, and h not indurated, 
id the edges are indented and raiseil. SimUar lesions are to be 

found generally in the vagina and \"ulva. 

(5) SyphUitic ulcer may occur on the eervix in three fi>nns; (a) 
as an ulcerated initial lejsion, (b) as broken-tiown papules, or (c) as 
a degenerated gumma. 

(a) The iniiial lesion is solitary and of great hardness. The 
ulcer has a sharp eflge ant 1 is of a diiiy rtMldish-brrmii color: its 
diischarge being of a greasy consistency. It may extend into the 
cervical canal in the cast* of a parou.s woman with open os cxteniunL 

(6) Ulcers from jmpule^H are generally Mmlti[>li» and are e]evate<l 
above the surrounding sm*facr* of tlie normal mucous membrane. 
Their siu^'ace is covered with disc^rganized white or yellowish tissue. 
Near them are to Ix» founil non-ulcerateil papules, esjx^cialty m\ 
the walls of the vagina and vuJva, 

(c) Gummula of (he cervix are verj^ ran^. They are described by 
Neumaim (Winter*s *'Lehrbuch der Gynakologischen iJiagnostik/* 
iii, Auf,) as occurring ab<»ut the os externum and on either or br^th 
the anterior an<l ix)sterior lips of the cervix. The ulcers are ellij> 
tieal in shape with sharply defined edges, shallow or deep, generally 
with yellow purulent covering. (lood-siztHi fungous granulations 
an" apt to be found on the siu-face. These ulct^rs are to \n^ differ- 
entiatixl from canc*iT»us ulcerations by their irregular and siimous 
borders, their rapid disintegration^ and the crater-Uke excavations 
of their tissues. Syphilitic lesions elsewhere in the Ixxly assist in 
making the diagnosis, the niicroseupe Ix'ing the court of last resort. 

DuGNosis OF Adkno-carcinoma of the Cbiuvical Canal 

In this form tlie diagnosis is of nece-ssity difficult. Palpation 
will show usually thickening of the cervix and perhaps a nodular 
feeling. If the external os is normal, a nodular thickening and the 
detection of a bloo<ly discharge from the os may U^ all of the sus- 
picious signs. 

If the OS is open because of tears, ulcerated and indurate! areas 
in the canal may be both palpated by the finger in the canal and 



276 DUGXOSIS OF MALIGNANT DISEASES OF THE UTERUS 

seen with a uterine or bladder sixx*ulum. With the aid of a sharj), 
stiff-siianktHl curette, tis^sue is removed for microscopic examination. 

In the infihrating variety where there is no ulceration, palpation 
ha^^ng shown localized thickening of the tissues, the external os 
should be (Hlatcnl under ether and a piece of tissue excised for a 
microscopic examination. 

In curetting the Ixnly and fundus of the uterus it is very easy 
to overlook thic> situation. The physician should bear in mind 
always that the cervical canal is one of the points of origin of 
cancer. 

Differential Diatjnoisis of Adeno-carcinoma of the Cervical Canal 

This form of cancer of the uterus is to Ix^ diflferentiated from 
intcri^tiiial niyomOj and chronic cervical endomeiriiis in old women. 

As to th(^ fonner, the infiltration of the tissues surrounding the 
center of the disease distinguishes carcinoma from myoma. In 
the case of the* latter the mucous membrane of a chi-onic endocervn- 
citis is mon* normal to sight, although not necessarily so to the 
touch, and the curette carries away little tissue. Tissue is removcnl 
and the microscopt^ tells the last word. 

Diagnosis of Cancer of thk Body of the Utekus 
(Adeno-caucinoma) 

The symptoms are the chi(»f guide to a diagnosis of cancer of 
the body of th(» iittTus. Bleeding alternating with a watery dis- 
charg(\, occurring in a woman who is past the menopause, and the 
exclusion of fibroids and of cancer of the cervix, make cancer of 
the body probable. Cancer of the tody of the uterus is more com- 
mon in nulliparte than in women who have borne children. Then" 
is sometimes a charactc^ristic odor to the uterine discharge in cancer. 
It can not Ik* descrilM'd, however*. A recurrent pain, similar to 
laI)or pains, coming on n^gular days and of several hours' duration, 
the so-called Simpson symptom, has lx»en described as character- 
istic of cancel- of tlu^ ])0(ly. This sort of pain is found also in myoma 
of submucous evolution and must \yo interpreted as the result of 
the stinnihition of tlie utiM'us by a fon^ign Ixxly which it is tr}dng 
to expel. There is nothing characteristic in the uterine discharge 
of cancer to distinguish it from the discharge from myoma, except 



CANCER OF THE TTERUS 



277 



tlmt on inierfjst'opif (*\nmination canrcr ciciucnts may fn* dis- 
tinguinlici! in it. A utfriuc ilischar^e oci'urmig m a woiuan pa.^t 
forty sljoiili] Icarl to an invt'sti^aticin. 

So, also, palpation gives no chiU'at-ttTistir iV'rliiig. Ttiore should 
Ix^ slight enlargement of the body; there may be tendenie^. In 
patients with very thin or lax abdominal walls it ma}^ Ijt* posHiible 
in exceptional causes to make* out a localized tumor in the Ixxly 
of the uterus. This ii^ unusual. 

The diagnosis is established by exploration of the cavity of the 
uterus, first with the sound and then with the curette forceps or 
the finger. The sound will tletect friable tissue, the eurt»tte foret^ps 
will remove it for microscopic examination. Every part, of the 
utc^rine ca\Hty must be reached by the curette, as the initial lesion 
may Ix* very small and easily overlookefl. 

The curette forceps are espfTially valuable in this case, for they 
pinch off and remove tiasue without tearing it to picxtc^s. The finger 
introduced to the fundus can recognize beginning cancer of the 
mucous membrane. 

In order to examine with the finger ether must he mlministered 
arul the cervix dilates! with steel branched dilators and large Hegar 
dilators, A metho*! devised by IL A, Kelly, consisting of an an- 
t<»rinr coIjMitomy antl ilivision of the ant(*rior wall of the eenix 
(sec page 94), is of value often in (exploring the interior of the 
uterus. As in the other forms of uterine cancer^ the microscojx* is 
the means of a sure iliagnosis. 

Dijferenlial Biagrwsi^ of Cancer of the Body of the Uterus 



Tlie tlifferc^ntial tliagnosis is a matter of the mien^scopic exami- 
nation. The physician should remexnlx?r that sarcoma of the endo- 
metrium, necrotic myoma, mucous poI\^i, the protlucts of eonc(*|>- 
tion, or hydatidifomi moles may Ix' found in the uterine cavity, 
Thf* characteristics of cancer of the fundus have Ix^en referretl to 
alreaily i page 269). 

fii^fore leaving the sul)ject of uterine cancer it is well to draw at- 
tention to the great difiieulty often experiencetl in determining 
whether a thickening in the* broa<l figaments is of inflammatory or 
of cancerous origin, It is w(41 to Ix^ar in mind that most tliicken- 
iiigp are the result of oltl |x*lvic inflammation. Cancer may super- 



278 DUGNOSLS OF M.\LIGNANT DISEASES OF THE UTERUS 

vcne, however, and then it may be assunKMl that all of the indura- 
tion is ihie to the cancerous infiltration. The history of the case 
Ls of some assistance in differentiating the two. 

If there has be(*n jx^Kdc inflammatory disease, it will be shown 
by a history of difficult and infected labors and abortions and a 
history of old attacks of "inflammation of the bowels." We have 
seen what are the usual routes of infection of the surrounding 
tissues in the different forms of uterine cancer, both as to the cellu- 
lar tissue and the glands. Then we know that cancer of the body 
seldom extends to the broad ligaments and to the lymphatic glands 
except in the late stages of long neglected cases, whereas cancer of 
the cer\acal canal extends to the surrounding tissues relatively 
early. 

THE DIAGNOSIS OF SARCOMA OF THE UTERUS 

Sarcoma of the uterus is of very rare occurrence. It is most 
often found between the ages of forty and sixty. W. A. Edwanls 
{Amer. Jour. Med. ScL, July, 1909) has recently collected 16 cases 
of sarcoma of the uterus in children who were fifteen years of age 
or younger. It forms about 4.8 per cent of all malignant growths 
and 2 per cent of all uterine tumors. (E. Hurdon, Kelly and Noble, 
" Gynecolog}' and Abdominal Surgery," Vol. I., p. 151.) It is a 
disease originating from connective-tissue elements as contrasted 
with epithelial elements from which carcinoma arises. There is to 
be noted in sarcoma not only a numerical increase in the number 
of cell (elements, a hyperplasia, but also a change in the original 
typ(», h(»teroplasia. The small round or spindle cells acquire large 
nuclei, many times larger than the nuclei of the original cells of 
the connective* tissu(\ There is great proliferation of the cells 
into the surrounding tissu(*s and later metastases by the blood- 
vessels to distant organs. The prolif(»ration is not everywhere 
uniform: largc^r and smalltT cells lie together, so that the distin- 
guishing characteristics of sarcoma are the change in the type of 
the cells and the dissimilarity of their arrangement. In sarcoma 
th(» tumor i)arenchyma is richly vascularized, carrying its owii 
blood supply; whereas in cancer tlu^ blood-vessels are containeil 
only in fibrous s(»pta. Therefore sarcomata arc full of blood and 
an^ not so apt to Ik* found in a deg(»nerat<*d condition. 



SARCOMA OF THE CT^ERUS 



279 



Three varietirs are jvcogiiiztHl by imtliologi.sts: si)in<llt^-cclled 
sarcoma; giant-celletl sarroiiia; and suiaJl muiuUcelletl sarcoma. 
The last is the mo!?t difficult to diapio.se mt(Tosco|>ieal]y, csjH'cially 
if only small pieces are funiishe*! from a eurettjiig. The disease 
may originate in any of the struetvires of the uterus where Cini^ 
nective tissue is found, in the mterglandular connective tissue of 




Tm, 113.— Roimd*€elled Sarcoma of the Body of the Ut-erus. (CuUon.) 

endometrium, in the connective tissue of the myometrium, 
^T about the blood-vessels. One of tiie most frequent si-ats is a 
preexisting myoma of submucous or interstitial development; 
the next most fre(]uent is the body of the uterus, and the least 
frequent is the cervLx. 

In mrcoma of the body of the uterus j if the disease originates in 
endometrium, there is a diffuse thickening and infiltration of 
Ihe endometrium, accompanied often by more or less definitely 



280 DIAGNOSIS OF MALIGNANT DISEASES OF THE UTERUS 

circumscril)ed outgrowths. The growth is soft and friable, con- 
sisting of a homogeneous brain-likt^ substance very well vascular- 
ized. 

Sarconiu of the muscular wall usually occurs as a circumscribed, 
nodular growth and rarely as a diffuse infiltration. 

Sarcoma of tlie cervix occurs in two forms, a polypoid tumor of 
soft consistency and smooth surface, attached by a broad base, 
or a tumor made up of many little blebs of tissue of different sizes, 
racemose in character, something like a hydatidiform mole or the 
grape-like vaginal sarcomata of infants. These latter tumors are 
sometimes called myxosarcomata. 

The diagnosis of sarcoma can not be made without the aid of the 
microscope. Metastases by way of the blood current occur in 
about a fourth of the cases of sarcoma of the endometrium, accord- 
ing to G. \Mnter. They are in the lungs, intestine, and peritoneum. 
The lymph glands are very seldom involved. Metastases from 
sarcomata of the uterine wall or myomata invaded by sarcoma 
are more frequent, being found in the lungs, liver, and intestine. 



THE DIAGNOSIS OF MALIGNANT CHORIOEPITHELIOMA 

Sanger in 1889 (M. Sanger, ''Ueber Deciduome," Cen^rott./. Gyn,, 
1889, Bd. 13, p. 132) reported a case of deciduosarcoma: a tumor 
developing in the uterine cavity after pregnancy and followed by 
metastases to distant organs. Soon other observ(^rs reported 
similar tumors under the names, Deciduoma malignum, Deciduo- 
sarcoma, Placentoma, Syncytioma malignum, Malignant hydatidi- 
form mole, or other names. 

Marchand (F. Marchand, **Ueber das maligne Chorioepitheliom 
nebvSt Mittheilung von zwei neuen Fiillen,'' Zeitschr,f Geb. u, Gyn.^ 
Bd. 39, p. 173) in 1895 and the following years showed that the 
tumor originates in the epithelial ct^lls covering the chorionic villi, 
and is of a fetal rather than a maternal (decidual) source, hence 
the name Chorioepithelioma, which has since been generally 
adopted by the many authors reporting cases. 

The disease consists of a tumor without sharply defined border 
developing in the mucous nK^nbranc^ of the body of the uterus 
(very rarely in the Fallopian tulx^ or the vagina) and invading the 



MALIGNANT GIIORIOEPITHELIOMA 



281 



mucoiis 8tnjrture. It is ilark iv\] hi color, of soft consii^nicy, 
and abundantly .suppliinl with blocML It has a, tcinlcncy to Ixtouil* 
gangrenous uml in timt rase lias a foul uihn-. 

The* s?urfat*o is apt to Ik* unevenly loljulatrd. On rross section, 
the Btructure is seen niicrosnopieally to In* made uj) of fibrtJiis 
septa and large spaces filled with extra vasat(*d, elottefl blood, or 
placental tissue. Larger or smaller nodules are to b* scc?n in tlie 
uterine muscle, which iM^eomes often very thin when the disease 
has nearly penetrated to the iMTitoneiun. Tlit* nit*tastases show 



Fui. 1 1 L — Choriix^ijithdiurnu nf the F*ostcrior Wall of ttiu rftTus. (Winter.) 



the same characteristics. In the later stages thcTe are numerous 
m(4;istasc^s from the growth, not only in the neighl>orhoo<l of th(^ 
uttTUs but in distant f»rgans, most eommonly in the lungs, and the 
disease proves fatal in a majority of cases. 

Th(» disease never oeeurs except after pregnancy, "most often 
after hydatidiform mole and alxirtion. It generally occurs oidy 
a few wet»ks after tlie pregnancy, but may h)e delayer! several 
montlis. 

The usual chain of happenings in the case of chorioe|)ithelioma 



282 BUGNaSIS OF MALIGNANT D1SE.\SES OF THE tITERrS 

18 as follows: hemorrlmges occuiTuig after abortion or tlie delivery ' 
of a hyflaticlifonii inol(% curetting anil the removal of tissue without 
stopping tlio blerilijig^ c|uirkly tleveloping aneraia, and signs of 
metastases in the king.^ (puiti, henioptymH, anil rise of temperature). 
It is plain that prompt hysterectomy is indicated in order to save 
life. In exeeptiona! eases tlie o\ami which has growia a chorioe- 
pitlielioma is (a) m the Fallopian tube and not in the uterus, and 
in still rarer cases (b) in the wall of the vagina. 

These cases are calkn:! Ectopic malignnnt chorioepithelioma. In 
the first.^ {a) the symptoms are those of extra-uterine pregnancy, 
and in the second, (b) they are th<^ mme as in the uterine variety. 
The primary disease in the vagina being more accessible to sight 



Fig. 115. — Metastasis m tlie Vagina from Chorioepithelioma of the Uterus. 

(Winter.) 

and touch, the diagnosis should be made more promptly than 
w^hcn it is in the uterus. 

According to J, Veit ("Das maligne Chorioepitheliom/' Hand- 
biich d, Gyn., il Auf., Bd. 3, 1908) microscopic study of the tissues 
shows that syneytiuin, Langhans' layer, and connective tissue of 
the chorion, when all present in the same case, are fomul primarily 
in the veins of a uterus that has hvim prcgnantj and esjiecially after 
hydatidifonn mole. If the epithelial cells of the chorionic villus 
proliferate rapitlly in the veins, iM^ing well nourisheth thr^ process 
is malignant. The factor which determines the malignancy of the 
growth is the proliferating power of the ej^ithelial eeUs and not 
the invasion of the veins liy tlie coTmrxiive tissue of the chorion. 

If by chance the proliferating epithelial cells of the \iUus get 



r^^^» 



MALIGNANT rHORIOEPITHELlOiU 



283 



into other tissues than the vdn.s» as, for ioHtaiit*e, into the ix^ri- 
toneum, the process ecases. A non-iimligitaiit form of the iliseast* 
has lx*en reported, aod at the jjresent time authorities are not 
agreed as to the rea.s<3n for the two forms or as to tlieir ditTer- 
entiation before the six^cimen reaches the pathologit-al la}x)raiory, 
therefore it iB safe to assume that every case of ehoriof*pithclionia 
is malignant and treat it accordingly. 



Diagnosis 

The diagnosis dr|>end8 on the api)areitt rccurrenro of a placental 
polyp after abortion or a hydatidiform mole, with hemorrhage, 
and a watery^ foul tUschargi\ Rapidly developing anemia under 
such conditions is a 8us[>icious sym[jtom, a.s tiie anemia dt'velops 
more rapidly in this than in any known disease. Ti.^sue removed 
by the curette or curette forceps is submitted to microscopic exam- 
ination. Better still the ei^rvHx is dilated until the canal will luhuit 
the phy.sician's fon^finger ant^l (hgital exploration demonstrates 
the prepuce of a soft tumor. 

The tissue of a chorioeijithohoma is much more friable and 
softer than that of a i)Iacental or otlier polypus. The uterus is 
found to b*^ srimewhat rnlarged when the bimanual touch is prac- 
ticed. In most eases it is not sensitive. 

In cases of hy<latidiform mole the physician should keep his 
patient under obst^rv^ation for several weeks after the mole has 
Invn delivered and should Ix^ar in mind th«' fiossibility of the 
development of a ehorioepithelioma. Early removal of a chorioepi- 
thelioma is attendetl by lasting cure. 



CH.\PTER XMI 
THE DIAGNOSIS OF DISEASES OF THE OVARIES 

Anatomy and age changes, p. 284. 

Anomalies, p. 285. Atrophy, p. 285. 

Displacements, p. 286: Undescended ovary, p. 286. Prolapse of the 
ovary, p. 286. Hernia of the ovan% p. 288. 

Inflammations (Ovaritis), p. 288: Acute ovaritis, p. 288; Diagnosis of 
acute overitis, p. 288. Chronic ovaritis, p. 290. Diagnosis of chronic 
ovaritis, p. 290. 

Tumors of the ovary, p. 291 : Modes of development, p. 292. Classifica- 
tion, p. 293. Malignancy, p. 293. Etiology and symptoms, p^ 298. Di- 
agnosis in general, p. 295. Diagnosis of small ovarian tumors, p. 296; 
Differential diagnosis of small ovarian tumors, p. 296. Diagnosis of large 
ovarian tumors, p. 301; Differential diagnosis of laige ovarian tumors, 
p. 305. Tables, pp. 308, 309. 

Complications of ovarian tumors, p. 315: 1. Adhesions and incarceration, 
p. 315. 2. Intraligamentous development, p. 316. 3. Torsion of the pedicle, 
p. 317. 4. Infection and suppuration, p. 318. 5. D^enerative processes, 
including malignancy, p. 318. 6. Rupture, p. 319. 7. Association with 
pregnancy, p. 320. 

Diagnosis of the different pathological varieties of ovarian tumors, p. 321. 

ANATOMY AND AGE CHANGES 

At birth the ovaiy is an elongated body, lying parallel with the 
Fallopian tube and resembling in shape a flattened cucumber. 
(See Fig. 117.) Its surface is smooth, its bonlers may be crenate, 
and it may have a longitudinal furrow. At puberty it has become 
transforuK^d into a smooth olive-shaped gland, grasdsh-pink in 
color, If inche.'- long (4 cm.), J to 1 inch broad (2 to 2.5 cm.), and 
J inch thick (1 to 1.5 cm.) and weighing about 2 drams (6 grams). 

From pulx^rty to the mc^nopause it maintains the same size and 
shape, but the smoothness of its surface is marred by scars, the 
results of rei3eated lacerations caused by the rupture of the ripe 
Graafian follicles. (See Fig. 118.) 

After the menopause* the ovary shrinks and becomes wrinkled 
and atroi)hic, and at the age of sc^vi^nty weighs about one gram. 
(Sec^ Fig. 119.) 

284 



ANOMALIES 



285 



ANOMALIES 

Congenital ab^eorc of iKitli ovaric.s is rair ami It^ lissociateil with 
defective dcvelo|>nipnt of tiio uterus and partial or coiii|>lcte al> 
sence of the vagina. Ah'^Miec of one ovary usually aeeonipanies 
defieiency of the eorresjxinding half of the uterus and tht* Fallupinn 
lube, and aUsenee or inisplaeenient of the kidney on the sanu* side 
of the body. There is on reeoni no reliable tlei>eription of a super- 
numerary^ ovaiy ; the lx>di(*s deseribe^l as sucli being eoqiora fibroj^a, 
small myomata of the o^^arian liganientj or lyai-tially detachetl tub<:rs 



^Parorttriumn 



titrftnitij. 



7^ 



nTsT 



UTERUS*! 



jV ARy 



■>*■ 



i 

Fimbria tttunca. 
Fra. 116,— The Ovary and Tube Seen from Bcliiiiil. i Ht-riU-.) 

of the parovarium. Faulty growth of the ovary is romrnouly 
associatal with the uti^rint- condition known as infantile uterus, 
with rudimentary uterus. 
Atrophy of the ovaries oeeurs normally at the mt^nopause. They 
become smaller and liardii- and the oophoron (the egg-h<*aring 
zone on the outside of the ovary) is transformed into a layer uf 
d(*ns4_» fibrous tissu*'. LminlUm atrophf/ is a shi'inkfvge in the sizr 
of the ovary oceurringsomrtimi^s in wnrnen wln> have nursi'd their 
children for a long tinH\ Ovarian atrophy has Ijeen reportc^l hi 
the exanthemata, myxedema. markiHl aiK^rriia^ and in diaf)etes. 
It is supposed to occur in connection with rajjidly acquired obesity. 



286 



DUGNOem OF DISEASES OF THE OVARIES 



At all events young women who have suddenly become fat fre- 
quently suffer with amenorrhea. On account of the increase in 
fat in the alxlominal walls it is not easy to determine a decrea^ in 
the size of the ovaries in these patients, but in certain cases atrophy 
has been definitely made out. 

In 1&(J0 I o|x»ncMl the abdomeix in a case of abeolute amenorrhea 
of eight months' duration following steaming of the uterine cavity 
at the hands of another practitioner. The woman was twenty- 
eight years old, the mother of two children. The ovaries were 
found to be partially atrophied as well as the uterus. 

BISPLACEMENTS OF THE OVARY 

(a) lTndef?cendetl ovary, (6) Prolapse of the ovary, (c) Hernia of 
the ovary. 

(a) Undescended Ovary. — The ovaries arc in close relation with 
the kiilocys in the embryo and they gradually move downward 



Fia* 117. — Ut^ru^ TtibeSi fmd Ovaries of an Infant Cue Mouth Old. 

to the pehi??, at birth lying on the psoas magnus muscle in close 
relation with the hitomal alxlorninal ring. They get to their 
normal situation in the adult soon after birth. It may happen in 
very rare instances that an ovarj^ may n^niain in the neighborhood 
of the kidney and may retain its infantile shajx*. If it is the right 
ovary that has faik>tl to tlescend the cecum also generally remains 
high up, in its fetal position. 

(6) Prolapse of the ovary may occur when from repeated preg- 



E 



1 



DISPLACEMENTS OF THE OVARY 



287 



nancies the ovarian and broml ligaments have been stTetched and 
suteequently not properly involuted, jx^niiitting the ovary to sag 
back into Douglas' cul-ile-sac. Also when an ovaiy is enlai-getl 
for any reason and thu^ gravitates of iti^ own weight to the pelvic 
fl(X)r. Misplacements of the uterus, such as retroversiou and 
rt^troflexion, are commonly a.^sociated with prolapse of the ovaries. 
Prola]>sed ovarien may be tender to touch, when we may asjiumc 
that they are the seat of inflammation, oranti.'i. In this event 



I 

I 



t/tero- Qv\r tA r 



Tube 





BrnAd tl^AtTieri 




Fig. 118. — Ovary urnJ Tube of a Wotuan liuring Sexual Maturity. 

they may cause suffering when pressed on during the act of defeca- 
tion, es{j€*cially the left ovary^ or during coitus. The diagnosis is 
established by the bimanual touch. Absence of the ovary in its 
normal situation and its presence at the base of the broa^l ligament 
as determined by recta! touch arc the diagnostic [joints. It is 
often difficult to differentiate a prolap^Ml «>vary from a small 
scybalous mass in the rectum. In oriler to do this successfully, 




288 DIAGNOSIS OF DISEASES OF THE OVARIES 

thoroughly cleanse the rectum by enema, and examine a second 
time. In some cases it is well to use the proctoscope to be sure 
that the upper rectum is free. If the ovary is tender distinguish- 
ing it is easier. 

(c) Hernia of the ovary is comparatively rare in adults but occurs 
not infrequently in infants under a year and a half old. It may 
occupy a hernial sac either alone or accompanied by its Fallopian 
tube. Ovarian hernia is more apt to occur as an inguinal than 
as a femoral hernia. Congenital hernia of the ovary is ver}' 
rare, but it may occur in the early months of infancy because 
the ovaries and tubes at this time normally lie in close prox- 
imity to the abdominal ends of the inguinal canals. (See Fig. 
206.) Many cases reported as heniia of the ovary are hydroceles 
of the canal of Nuck. Hernia of the ovary may occur at any 
age up to the seventy-third year. The diagnosis can be made 
definitely only by operation. It is difficult to be sure of the 
alisence of the ovary on one side. A hernia — preferably an 
inguinal hernia — ha\'ing a tender body in it, while at the same 
time the ovary on that side can not be palpated in its normal 
situation, makes a probable diagnosis. 



INFLAMMATIONS OF THE OVARY 

Ovaritis may be acute or chronic. The acute form occurs in 
infections following labor or abortion, gonorrhea, typhoid fever, 
miliary tuberculosis, the acute exanthemata, or numips. The 
ovary is erilarge<] and congested, the oophoron or the paroophoron 
Ixiing involved, or both. The tissues are infiltrated mth serum, 
leuco(*ytes which have (»scap(Ml from the blood-vessels, and some- 
times with blood. If there is a large colk^ction of blood, a hema- 
toma of the ovary is formed. Absces.s of the ovary may be the n»sult 
of sc^vere grad(»s of inflammation and a tumor which reaches the 
size of an egg may ev(*ntuate. There an* apt to be adhesions to 
th(» surrounding structun^s, such as tlu^ Fallopian tubes and in- 
testines. The absct^ss may niptun* into the intestine, bladder, or 
vagina. It has been known in ran* cases to lireak into the general 
peritoneal cavity, causing fatal peritonitis. 

Diagnosis of Acute Ovaritis. — Pelvic pain aggravated by move- 



INFLAMMATIONS OF THE OV.UtY 



289 



Bnt of the body or by defecation, and tenderness on pres8ure in 
the ovarian regions, are characteristic of a niild attack of ovaritis. 
Chills and marked elt^vation of the Ixniy temperature are to be 
expected if suppuration occurs. If there is peritonitis of any 
extent there will be rigitlity of the abionien and a rapid and small 
pulse and increased pain. If it is [X)ssible to palpate the ovary 
it will be found enlarged and ex([uisitrly tender. Commonly the 
rigidity of the alxlorainal walls prevents exact differentiation of 
the structures involveil An abscess is usually fixeiJ in a mass of 
exudate. Fluctuation may be nmdo out by rectal palpation, but 



yy 



Fjg. 1 UJ.— Senile Ovary and Tube* 

often the wall of the aliscess is so tiiiek that this is impossible. 
In the case of acute ovaritis it is impossible to distinguish exactly 
between ovaritis and salpingitis. If the disease is right-siiled we 
must, if possible, eliminate appendicitis. The history of the onset 
is the important jjoiot in distinguishing the two. Acute pelvic 
I inflammation is generally preceded by a vaginal discharge or other 
uterine symptoms such as dysmenorrhea, whereas in appentlicitls 
there is a histor>' of digestive disturbances, such ns diajrhea alter- 
nating with constipation, or nf previous attacks of pam in the 
right lower abdomen. The pain of pehic disease is dull and steady 
and is situated deep in the pehds, pressure over Poupart's ligament 
19 




290 



DUGNOSIS OF DISE.\SES OF THE OVARIES 



occasioning great suffering. The pain of appendicitis is sharp 
and colicky and is higher in the abdomen and is more diffused. 

If the appendix hapjx^ns to be in the pehis or if there is much 
I)eritonitis it is impossible to distinguish the two affections. 

Chronic ovaritis may follow an acute ovaritis or it may originate 
in an infection of the uterus, especially in gonorrhea. It is also 
found in the presence* of fibromyomata and krge ovarian tumors 
of the opposite side, although the disease is generally bilateral. 

The oophoron is usually affected, the Graafian follicles often be- 
coming enlarged and causing atrophy of the stroma because of their 
size. Such a condition is called small cystic degeneration. In certain 
cases the entire cortical region of the ovary (oophoron) is trans- 
fonned into little cysts containing a clear fluid, the ovum having dis- 




FiG. 120. — Diagram Showing the Cyst and Tumor Regions of the Ovan*. 

(After Bland-Sutton.) 

appeared. Now and then a few noiTnal follicles may be found. In 
some cases of chronic ovaritis, thc^ stroma and not the follicles is in- 
vo1v(h1. In the late stages of this disease the ovary is found small and 
scirrhotic with a puckered, uneven surface, as from many scars. 

Diagnosis of Chronic Ovaritis. — ^There is nothing pathognomonic 
in the symptoms of this disease. There is apt to be pain in the 
ovarian n^gions, and scanty menstruation if the ovarian stroma 
has Ix^en destroyed, also dysmenorrhea. The ovaries may be 
tender to th(» touch; often they an* not. The bimanual touch may 
determine follicular enlargemc^nt or a nodular feel. In only ex- 
ceptional ca,s(^s when all th(^ factors are favorable, more especially 
at an examination under an anesthetic, can a small cirrhotic ovary 
be diagnosed. 



OVARIAN TUMORS 291 



OVARIAN TUMORS 

We have considered already certain states of the ovary that 
strictly may be classed as tuniors, for instance, "small cystic de- 
generation'* and mflammatory conditions with enlargement. 

Let us now take up ovarian tumors propcT, counting as tumors 
all enlargements of the ovary greater in size than a hen's egg, using 
Pfannenstiers classification ba^nl on the origin of the tumor. 
(Veit's "Handbuch," J. Pfannenstiel, "Die Erkrankungen des 
Ovarium.'') 

A. Nox-Proliferatixc; Cys'fs. 

(Follicular cysts; Cysts of thcj corpus luteum.) 

B. New Formations. 

I. Parenchyniatogenmis Tumors. 

(Tumors arising from germinal or follicular epithelium^ 
or from the ovum.) 
1. Epith(»lial New Formations, 
(a) Cystoma serosum simplex. 
(Simple cyst.) 



(h) Cyst adenoma 



Pseudomucinosum. 

(Multilocular cysts.) 
Serosum. 

(Papillary cysts.) 
(r) Carcinoma. 
2. Kmbrj'omata. 

(Tumors springing from the ovum.) 
(a) Dermoid cysts. 
(h) Teratomata. 
II. Stromatoyenou.s Tuwors. 

(Tumors arising from the connc^ctive tissu<\) 

1. Fibroma. 

2. Sarcoma. 

3. Peri- and Endothelioma. 
C. Mixed Tumohs. 

(\'arious coml)inations of tlu* tumor processes enumerated.) 

Fig. 120 shows diaiirammatically the dilTerent portions of the 
ovary affected by neoplasms. 



292 



DIAGNOSIS OF DISEASES OF THE OVARIES 



Modes of Development of Ovarian Tumors 

The accompanying diagrams indicate the method of develop- 
ment of the pedicle of a tumor and the arrangement of the peri- 
toneum in the case of the normal ovary, a free ovarian cyst, an 
intraligamentous cyst, and an adherent ovarian cyst. It is plain 
that the broad ligament, the Fallopian tube, the romid ligament, 



J^icle. 



'^tube. 







Figs. 121-124. — Four Diagrams Sho\ving the Method of Formation of the 
Pedicle in the Different Sorts of Ovarian Tumors. 

and th(^ ovarian ligament are inckided hi varying degnx*^ in the 
pedicle of a large non-adherent ovarian tumor. Commonly the 
Fallopian tube is much elongated and spread over the surface of 
the tumor, the round ligament comes on to the anterior face of the 
tumor, and ih(i ovarian ligament is much enlarged and lengthened. 
In th(^ ciise of tumors d(»veloping Ix^twc^en thi» layers of the broad 
ligament, or of adherent ovarian tumors, the conditions are as 
shown in the diagram. . A j)arovarian cyst may lie free in the 



OVARIAN TUMORS 



293 



pelvis atta^jhed only by a pcHliele foniicd from the broad ligament, 
and it is not unusual to fintl such a cyst as a complication of a small 
ovarian tumor. 

CLASSIFfCATfON 

Ovarian tumoi*s have lx»en generally elas.^ifie<i as solid or rystic, 
and benign or malignant. As will be seen from the classification 
of Pfannenstiel, such a division is arbitrary and many of the tumoi*s 
are both solid and €>'stic, and also benign and malignant. This is 
shown by careful microscopic examination in the pathological 
laboratory where a unilocular cyst will be found often to have 
small cysts in its walls, or tratecuk^ in the cyst walls, denoting 
former subdivisions. Some of the multilocular cysts show papillary 
masses in certain regions^ while m other placets small dermoid cysts 
may be discovered, and even areas of cancerous degeneration. 



Malignancy 

A benign turner is one which tloes not tend to recur when extir- 
pated, 3i> Well as one which does not implant itself elsewhere or 
mvade the tissues. 

A malignant tumor sigiiifies a groi^lh which tends to destroy life 
by invasion of tlie surrounding tissues as well as one wiiieh dis- 
tributes its elements by metastasis to other parts of the body. 

In a general way one may say that the cystadenomata (multi- 
locular cysts), the parovarian cysts, the filiroids of the ovary, and 
the dermoid cysts are benign; the carcinomatu and sarcomata are 
malignant, and the paj)ilhiry tumors are on the border land. That 
Ls to say, the papillary cystadenomata tend to implant their ek^ 
ments on the surn>unding structure's, there to grow, but they do 
not invade the underlying structures as do the carcinouiata and 
sarcomata. 



Etiology and S'iTurroMS 

Ovarian tumors are found most often during the time of sexual 
activity in the life of women, but may occur at any age, Chiene 




The eontrolling factors are unkno\\Ti. The symptoms consist, 
during the t-arly ^stages of the gruwih of an ovarian tumor, in the 
usual syndromata of uterine disease, and may be of little moment 
to the patient, so that her attention is not directal to the pc4vis* 
They are menstrual disturbances, — such a^ dysnienon*hea, raenor- 




OVARUN TUMORS 



295 



rhagia, or scanty menstmatioij, — a senst* of weight iii the i>['hds» or, 
if there is peritonitis?, pain, Wlien the tunior attains a considerable 
size, 50 that it fiDs the peKi.s or rises out of it into the abdomen, 
there are presmre sympkun.s. Th<'so are vehiea! or rectal tencn- 
IHQS, frcKjuent mieturition, and constipation; in the case of large 
tumors, edema of the vulva and of tlie lower extremities caused 
by pressure on tlie iliac veinvs: also hemorrhoids. In rare cases 
there have been noted albuminuria and suppression of uj'ine from 
hydronephrosis causcnl by pressure on the ureters. Other symp- 
toms are jayndiee from occlusion of the bile ducts, ascites from 
pressiu^ obstruction to the portal system, dilaltHj veins in the 
skin of the aLKloinen^ the occurrence of the white lines m the skin 
kno^^Ti as lineie albicantes, occasional umbilical hernia, and de- 
rangements of digestion and tlysi>nea. 

Pain in the aklouKHi is a s}in|)tonj of adhesions, as a rule, and great 
care should l>e obserw-nl in taking the aiianmesis to get the exact sit- 
uation, character, and duration of the pain. Pain is causeil also by 
traction or torsion of the ijediele an<l l>y secondary changes in the 
contents of the cyst involving adhesions to the sensitive parietal 
peritoneum. 

The fades oi^arinn is a pfHniliar facial expreasion that is pathog- 
nomonic of the late stage of large ovarian tumors. It consists 
of an anxious, careworn look; the face is pale and shriveled, there 
being wrinkles m the cheeks, and it looks longer; the nostrils are 
wide and the lips thin, the space Ix^tween the eyelids and the l>ony 
margin of tlie orbits is sytike!i. The face iloes not have that 
yellowish hue characteristic of the lat^ stages of cancer, nor yet 
the full appearance of the face of tlie pregnant w^oman. 

There is also to be noted in large ovarian tumors a los< of tiesh 
over the chest ami shoultlers, |»robably of a piece with the atrophy 
of the face just described 



Diagnosis in Gen^eral 



In considering the diagnosis of ovai'ian tumors it is convenient 
to di\ide them into small tumors, tliose that lie wholly within the 
pehic cavity proj^er, and kirtje iunm*s, those that he for the most 
part in the abdominal cavity. We will discuss the diagnosis and 




296 DIAGNOSIS OF DISEASES OF THE OVARIES 

the differential diagnosis of each, then take up the complications 
of ovarian tumors, and finally say something of the diagnosis of 
the different pathological varieties of tumors, as far as they can be 
distinguished without operation. 

The important factor in the diagnosis of all ovarian tumors 
is to determine the relation of the tumor to the uterus. 

If it can be shown that moving the tumor moves the uterus, or, 
conversely, that changing the position of the uterus moves the 
tumor, there is a probability that the tumor is ovarian. On ac- 
count of adhesions and intraligamentous development, all ovarian 
tumors are not movable. The tumors of medium size, those that 
have risen out of the pelvis but have not yet distended the ab- 
dominal walls to excessive dc^gree, are easiest to palpate with 
reference to their connection with the uterus. To perform the 
palpation to the best advantage, use is made of the bimanual 
vagino-abdominal touch. 

With the forefinger against the cervix, push the tumor in the abdo- 
men or pelvis to one side with a quick movement of the hand on the 
abdomen. At the same moment the cervix will be felt to move be- 
cause of the pull on the pedicle of the tumor. Sometimes, but not 
often, a quick push on the uterus by the finger in the vagina will be 
transmitted to the tumor, as detected by the hand on the abdomen. 

To palpate the pedicle the cervix is grasped by a double tenacu- 
lum held by an assistant while the physician practices the bimanual 
recto-abdominal touch, with two fingers in the rectum. (See Fig. 
126, page 301.) 

In this way it is possible sometimes to get a good idea of the 
situation, size, and length of the pedicle of a tumor. As pointed 
out by John A. Sampson ("Surgery, Gynecology and Obstetrics," 
1907, Vol. IV., p. 685), traction on thcj pedicle of an ovarian tumor 
causes pain. Also twisting of the pedicle, as determined by opera- 
tions performed on patients by the aid of local anesthesia, causes 
pain which is referred to the pelvis on the side on which the pedicle 
is situated. 

Diagnosis of Small Ovarian Tumors 

Those tumors, which lie entirely within the cavity of the true 
pelvis, are diagnosed by the bimanual touch, both vagino-abdominal 



SMALL OVARIAN TUMORS 



297 



and rectoaMoniinal. In the case of the small tumor it is diffifult 
to make out the eharacteristic^ of the pedicle. One lietermines 
this in 8ome ca.ses a« de,serilx'<i al)ove. We try to aseerlain the 
ixjmtion, size, form, and density of any given pelvic tumor; tht^n 
it,s relation to the utenis. If tlie tumor is small there i*s a likeliliond 
that the uterus can be placed and its size ami shape defined by 
touch. In the larger tumors, those filling the pelvis, such palpa- 
tion is difficult or impossible. In thi.s event the sound must be 
passed to determine the location and relative size of the uterus. 
As a rule, ovarian tumors are round. This is always the ease with 
the cysts, the solid tumors \wmg generally, but not invariably, 
round, A fluctuating consistency can be ma^le out in most cases 
of cysts, A small-size<l ovarian cyst is to be looked for in the 
situation of the ovary, and is moval>le (rarely a<!lierent) ; an intra- 
ligamentous cyst lies to one side and behind the uterus, and is 
inunovable, A cyst may lie in front of the uterus, rarely, and, of 
course, there nmy be two ovarian tumors, one on each side. 

Differentiaf Diagnos^^is of Small Omrian Tunwrs 

We must rule out.: 

1. Ovaritis, 

2. Subperitoneal fibroid. 

3. Parovarian cyst. 

4. Hydrosalpinx, hematosalpinx^ and pyosalpinx, 

5. Encapsulated peritonitis, or inflammatory exudate. 

6. Echinococcus cyst. 

7. Extra-uterine pregnancy. 

8. Early normal pregnancy, or cornual pregnancy. 

9. Distended m*inarv bladder. 



I. Ovaritis. — Tumors of the chronic form of ovaritis are seldom 
larger than a pigeon's egg, but the acute form resulting in abs<.'ess 
may be of considerable size. Here there is fever, and the tumor is 
of recent occurrence, an acute affair. The tumor is tenrler, and 
there is pelvic peritonitis in varying degrc^ss of intensity as evi- 
denced by rigidity of the abdominal walls. Also there is generally 
a history of infection. 

3. Subperitoneal Fibroid.— The differentiation in this case is often 



298 DIAGNOSIS OF DISEASES OF THE OVARIES 

a difficult matter and depends entin^ly on the findings from palpa- 
tion. The consistency of an ovarian cyst is softer than that of a 
subserous fibroid. As a rule, the fibroid is more intimately allied 
vnth the utc^rus, and in many cases the pedicle is short and thick 
or the growth is sessile. It helps in the diagnosis if other fibroid 
nodules can be distinguished in the substance of the uterus, for 
fibroids are apt to be multiple. The coexistence of ovarian cyst 
and fibroid is not an uncommon occurrence. 

In the case of an irUerstitml fibroid the uterus should be enlarged 
and menorrhagia is apt to he a symptom ; the passage of the sound 
will show an increased depth of the uterine cavity. 

If, by any chance, both normal-sized ovaries can be palpatcxl, the 
tumor is a uterine fibroid. 

3. Parovarian Cyst. — Parovarian cysts are generally relatively 
small in size, therefore they are put here. They may be large, 
however. The cyst arises from the epoophoron, is generally uni- 
locular, and has a thin wall, with clear serous contents. It is situ- 
ated between the tube and ovar>' and is intra-ligamentous in growih; 
therefore, when the cyst has developed the tube is on its upper 
surface and the ovary Ix^low it. In extremely rare cases the ovarj^ 
may be palpated by the fing(T in the vagina on the under surface 
of the cyst. As a rule, the differential diagnosis can not be 
made. 

4. Hydrosalpinx, Hematosalpinx, and Pyosalpinx. — ^The accumu- 
lation of serous fluid, blood, or pus in the Fallopian tube gives it a 
more or less characteristic shape. This is a strong diagnostic 
point. A pyriform swelling with its small end at the uterine horn 
is indicative of a dilated tube. In the case of hydrosalpinx and 
hematosalpinx there is, as a rule, no complicating jx>ritonitis, 
therefore the diagnosis is easier than in the case of pyosalpinx, 
which is apt to be surrounded by exudate. Hydrosalpinx anil 
hematosalpinx never reach the great size of exceptional cases of 
pyosalpinx. It is unusual for any variety to be more than an inch 
and a half (3 cm.) in diameter or five inches (12 cm.) long. The 
hydrosalpinx has a thin wall, and fluctuation can be determined 
without much difficulty; pyosalpinx ha.s thick walls because of 
inflammatory' action in thc^ tube and also in the peritoneum sur- 
rounding it, and it is not ea^^y to make out fluctuation. 

5. Encapsulated Peritonitis. — If a (juantity of serous or purulent 



SMALL OVARIAN TTIMORS 



299 



exutlatc in the case of pvl\'\v iN*ritonitis, or n qiuuitity of nsritic 
Hiiid biH^'onies encai>sulate(l by peritoneal adh(»j«ion«, the c*on(liti(»n 
may b: mistaken for a eysttr tumor of the ovary. Such a eondi- 
tion IP relativt'iy rare, however. Generally there is evidence of 
tul^TCulosis or careinosis or aetinoinyeosis of the peritoneimi and 
the manifestations of the disease in the general cavity of the peri- 
toneum oA'ers^hadow those in the (R*l\ie cavity, Sueli circum- 
si^rib^l collections of flui<l in the |x>lvic cavity have an irregular 
shajic and are not often nnrnd. Also fluid is apt to be present hi 
other {Kirtions of the peritoneum, 

6* Echinococois Cyst. — Kchinocoeciis cyst of the pehis is rare. 
Primary ecliinoeorcus disease of the ovary is unknown, but it 
occurs in tln^ fnllowing situations in the jyehis; (a) the uterus* 
(b) the mesometrium, (c) the im^Ivic lj<^nes, (d) the omentum, aritl 
(e) the Fallopian tubc*s, ^\l.so downward extension of hydatiil 
disease of the hver may reach the jx^lvis, Eeliinococcus cyst is 
round and fluctuates; but, as a rule, is more distended and has 
thicker walls than an ovarian tumor, an*! it is generally densi^Iy 
a/_lherent to the surrounding structures. Bland-Sutton (^'Surgical 
Diseases of the Ovaries ami Fallopian Tul>es," 1891, p, 183) says 
that a '* {X^culiar sign — liyatid fremitus — can sometimes be obtainnl 
by placing the palm of the left hand u]>on the tumor and shar|>ly 
jMTcussing with the finger of the right. It is a peculiar tremor or 
thrill, only felt over a hyatid cyst." In this country hydatid dis- 
ease is very rare. 

7. Extra-Uterine Pregnancy* — ^lliis gives a history of pregnancy. 
Before rupture there Is a boggy fluctuating or elastic tumor at the 
side and Imek of the utenjs. It is the shape of a distended tulje. 
Ltx>k for i>ui7>le discoloration of the vaguia with increased dis- 
charge, and for changes in the breasts together with uterine en- 
largement and softening of the cervix, also pain on moving the 
cervix. Alx)ut the time of intra-ab<lominal rupture of the preg- 
nant sac the endometrium casts otT a motUficd decidua of pregnancy 
with more or lea^ uterine hemon*hage. At the time of rupture th«^ 
symptonLs are those of intra-ahlominal hemorrhage and an* urgent. 
There is a fulness in the cul-<!e-sac with alnlominal distention, 
rapid, fwble pulse, severe i>ain in the alxlomen, and collapse. If 
in a chronic case a hematocele has form(*fl, there is a boggj" mass 
m the cul-de-sac, generally filling the pehis, the uterus being in 



300 DIAGNOSIS OF DISEASES OF THE OVARIES 

front. There may be a history of repeated attacks of pain recurring 
at irregular periods. 

8. Normal Pregnancy. — Early normal pregnancy, particularly if 
the pregnancy begins in one horn of the uterus, may be mistaken 
for ovarian cyst. It should not be forgotten that the two condi- 
tions frequently coexist. First, the history indicates pregnancy. 
Inquire for amenorrhea and morning nausea and whether there 
has been coitus. The uterus in pregnancy is antoflexed, there is 
bulging of the lower uterine segment anteriorly, the uterine tissues 
have a peculiar elastic feel and are compressible by bimanual 
touch (Hegar's sign; see Fig. 178). The cervix is soft and there 
are increased vaginal discharge and purplish discoloration of the 
anterior vaginal wall and introitus vaginsp, noticeable as early as 
the sixth week in some instances, though usually not quite so early. 
The breasts are full, the veins showing in the skin; the areolse are 
pigmented and show enlargement of the follicles. There may be 
secretion from the breasts. In the case of pregnancy in one horn 
of a bifurcated uterus the history of pregnancy is to be obtained. 
There is no bulging of the lower uterine segment, but the other 
signs of pregnancy are the same. There is no fluctuation in the 
pregnant uterus until the stage of "ballottoment." This is not 
available as a diagnostic sign until the twenty-first week of preg- 
nancy when there is sufficient fluid in the amnion and the fetus is 
hea^y enough to give the characteristic feeling as the fetus bobs 
about when jostled by the sudden impact of the examiner's finger 
in the vagina. 

9. A Distended Urinary Bladder. — If the ndes for the preparation 
of the patient for an examination have been observed (see Chapter 
IV., page 23) it will have been learned that the patient has been 
unablcj to urinate, and therefore a catheter has been passed. It 
sometimes ha{)pens that a patient is unabk^ to speak the language 
or is unconscious, and the question of ovarian tumor arises. It 
is safe to i)ass the catheter if there is the slightest doubt that the 
bladder is empty. Upon palpation the full bladder is not so mov- 
able as an ovarian cyst, as a rule, and the uterus is retroverted 
under the bladdcT. Dribbling of urine is apt to be a symptom of 
an overfilled bladder. 



302 



DUGXOSIS OF DISE.\SES OF THE OVARIES 



ciaii may Iw* able to distinguish the situation and characteristics | 
uf the \khMv. (See Fig, 120, page 30L) 

Inspection. — Inspcetion of the ahdonien of a woman having a 
riioderatt'ly large ovarian tumor will show the enlargement most 
]>t'onouneed o!i the iAde from w^hit^h the tumor has sjjrung. This 
is not the case with very large tumors. As a rulr* the enlargement 
is in the lower j>ortion of the al>t!oTnen. II C Hirst (^* Diseases of 
Women," Serond E(htion, p, /k]9) has seen three eases in which 
an ovarian tumor wus in the upiKT alxlomen — twice clue to tight 
lacing and once to tlie fact that the tumor was elevated in preg- 



Liull 



lympanjttc 



^ 



-Tympimitic 



iS-^-^ ^~>^ 



iS. 



Fwi. 127. — Diiignim of a Cross Section uf llie Bcwiy in (he Tiise of an Ovarian 

Tumor. 



nancy, iTecame adherent to the liver, and did not descend with 
invijiutinn of the uterus. 

When the tumor has Ihh'u long existent we expect to find the 
fttriefS ovarina and lrj.ss of flesh about the chest and sliouldcrs. 
Unless ascites is pi-esent or the tumor is excessively large, theits is 
n(> bulging in tlie Hanks. 

Palpation. — Palpation usually shows a fluctuating tumor, more 
distinctly felt, on the affected siile. Thv elasticity will depend on 
the sort of tumor present, and on tfie tenseness of the cyst. If 
the tumor is very tense it may feel like a solitl mass. It is rare 
for Bolid tissues to prtMlominate in ovari.Hn tumors. Nodules may 
be ft>lt and !t>culi of a multilornlar tumor if the aUhKininal walls 
are thin. If the walls are verv tense or tliick it is neeessan^ often to 




LARGE OVARIAN TIMOR^ 



303 



mlmmiKtcr an aiu'sthutie bcforo a satisfactory examination can 
be inatlr. The mobility of the tunior ilcpencls on the lerij2:th of its 
}K'(licle, the relation lM:*tweeii the .size of the tumor and the ^ize of 
its alxloinen, and the presc^nee of atlhesinns. 

By means of the ItiMiaiiUiil vagiiioalxloniinal or recto-alHloniinal 
touch it may Ix' poanible to rk^terniine that the uterus is not eii- 
lurgecl an<I is ^!e|>arat»' from the tumor^ and the pedide may l)e 
ma|>ped out by traetinn on the uterus. Also the coimection of the 
tumor may Ix* made jilairi l»y moving the tumor suddenly, the im- 



-^*v 



v^^ 



a\^ 



^ 



Flo. 128. — LariTi^ Parnvarian Cyst 8c^n in Prufile. (Kelly.) 

puke transmittrii tn \\\v uterus Ix^ing apj^reeiateil by the fioger in 
the vagina or reetuni. 

Percussion. — W'itli lln' patient in tlie dorsal position the tumor 
oceupii'8 the lower anterior portion of the alxlomen. The intes- 
tin(»8, helil Ijy their mesentery, are nearer the diaphragm and 
at the side^s of the tmiior; therefore tyinpanitie resonance is found 
in the epigastriimi, flatiieas over the tumor, and dullness or mixli- 
fied resonance in t!ie flanks. These areas of resonan<M', flatness, an<l 
dulhi(*Ns do not cliange with change in the [losition of the patient, 
as n'ganb the sitle pasition or the f^tanding position. If the turum* 
contains fluid, si jHTcussion tmve may be elieittnl by [ilacing a hand 
on each side of the alxlomen and then tapping witti tlie finger of 



304 



DUGNO^IS or DISE.VSES OF THE OVARIES 



one hand. A vibration will be felt by the opposite hand. If 
the abdominal walls are vciy fat the fat may transmit a wave by 
itself; therefore, to eliminate this fat wave have an assistant place 
a hand with the uhiar edge down along the middle line of the ab- 







Fig. 129. — The Various Abdominal Organs from Which Timiors May Arise. 

(Kelly.) 

domen and press firmly. If the fluid in the cyst is thick, as in 
dermoids, the percussion wave may Ik» slight or absent. 

Measurements. — Measurements of the abdomen show an incrcas<» 
or decrease in the size of a tumor from time to time. They arc 



LARGE OV.IRIAN TUMORiJ 



305 



made with a tajx* mca^surc? at some (Icfmitc point, as aliotit tlic 
body at the umljiliciit!, or at tho anterior ^ujKTior f^pine^ of the ilia. 
Other measurements are, the distance from tlie tip of the eiisi- 
form cartilage to the upixT margin <»f the sympliysis pubi.s antl 
a measurement made with the pelvimeter, the patient btnng in a 
standing position, fronj the upper apc^xof Mieliaelis' rhomfjoid area 
on the baek over the saerum, to the most ]>rominent [joint of the 
tumon These measurements must be taken eacli time with the 
patient in exactly the same position, wliether standing or on 
the side and always with tlie Ixjweb free. 

Aspiration or tapping an ovarian tumor is never justifialile a,s a 
means of diagnosis, and exploratory incu'^mi is to be praetict^l only 
when it is impossible to make a diagnosis and all the prejiarations 
have been made for a complete operation. 



Differential Diagnoaiis of Large Ovarian Tumors 

We must rule out: 

1. Pregnancy. 

2. Ascites. 

3. Fibroids. 

4. Aecunnilations of gas or fecal matter in tlie intestines, 

5. Fat or tumors in tlie alxlominal walls, including ''Phantom 

Tumor/' 

6. Cyst of tlie panei*eas. 

7. Tumors of the spleen, hv<,"r, and kidneys, 
S, Cyst of the omentum. 

9* Eehinococcus cysts- 
10. Dilateil stomach. 
n. Disiendal urinary bladder, 

I. Pregnancy.— It should be tissumed, mitil the contrary has 
been proven, tliat every abiominal *»nlargenient in a woman is 
due to pregnaney. In this way many enjbai'ra.Nsing mistakes will 
be avoided* The diagnosis of early pregnaney has bi'en eonsidered 
in treMing of the small ovarian tumors- Advanced pregnancy is 
to be excluded by t!ie history. It is possible to have amenorrhea 
in ovarian tumor, especially where both ovaries have become dis- 

20 




306 



DIAGNOSIS OF DISEASES OF THE OVARIES 



organized by the disease affecting them, but it is unusual. Morn- 
ing nausea and vomiting during the early months, or salivation 
and heartburn and swelling of the breasts, are characteristic of preg- 
nancy. Sometimes these symptoms have occurred at a given 
time with previous pregnancies. Ask whether they have bec^n 
observed this time since the patient first noticed the enlargement 
of the abdomen. 

Quickening is usually noticed at the end of the sixteenth w^(»ek 
of pregnancy. The signs of pregnancy in the later months an* 




Fig. 130. — The Height of tlie Fiiiulus I'teri iit the Various Weeks of Pregnancy 

(Aft^r Zweifel.) 

softc^iing of the cervix, increased vaginal discharge, ballottoment 
after the twenty-first week. Fluctuation in the uterus is vcTy 
indistinct unless the litjuor anmii is hi (wcess and the uterine walls 
are thin from juiy cause. By can^ful palpation the intermittent 
rhythmical contractions of the pregnant uterus may be felt as 
early as th(^ fouith month. A good deal of patience, gentleness, 
and skill ai'e necessary to get this sign. Purplish discoloration 



LARGE OVARIAN TUMOK8 



aor 



of the viilva aiid anterior wall of Uir- vagbia are to Ik? ma^ic out fmin 
the sixth to the twelfth week. If milk or colost rum can l)c squeeze^ 
from the breasts it is an inifxirtant imiicatiou of prc^iancy. 

Fetal heai-t sounds ca!i h} heartl aftiT the twentieth wei'k, and 
fetal nio%'enients can Ix^ felt after tlie sixte<^nth Mxrk unless the 
fetus is deacL The tumor has develo[X'd relatively rapidly; there 
is pigmentation of the areohe of the nipples, and of the hnc^a alba 
in sonic eases; edema of the ankles is not uncommon after the 



^ 



^-^V 



'r*, 



Jtia£i^ 



,_^*^ 

^:^ ^ 



Flu. 131-— Iht' Al"lonien of Ascit4?« Seen in Profile. (KrllyJ 



BPventh month; the face shows sometimes the faeies uterina^ a 
fnlhii'ss al>out the eyes and fn>ut of the elieeks. 

Lin the ease of an ovarian tumor theix^ is no softening of the 
cemx; the tumor is distinct from the uterus and is of gradual 
development; thert* is no ballottement and tlien* are no fetal heart 
sounils or moveTuents; also there is absence of [Jirniientation of the 
areohe and the linea alba; edema of the ankles is rare, excej>t after 
P tumor has cxisteil Sfweral years; the superficial veins of the 
alxiouien are enlarged, and the faeies ovarina is pre-sc»nt in the 
vii^* of long-existing tumors, 

Hydranmios, an excci^i^ of anmiotie \Uiu\, lias M many a surgeon 
to diagnose ovarian cyst. A careful study of the hisiorjr, synijv 
toms and signs of pregnancy and ovarian tumor ought to make 



308 



DIAGNOSIS OF DISEASES OF THE OVARIES 



differentiation relatively easy and sure. In ovarian cyst the 
tumor is of less rapid development, there is no ballottement, and 
the tumor is more on one side than the other, and, most important, 
it is distinct from the uterus. 

2. Ascites. — ^An accumulation of fluid in the peritoneal cavity 
may accompany an ovarian tumor, and in such a case the diagnosis 
is difficult, and may be settled exactly only at the operation und(T- 
taken for the removal of the tumor. 

The following table, taken from Dudley's "Gynecology,'' with 
modifications, gives the points which serve usually to distinguish 
ascites from ovarian cyst. 



Ascites. 



Large Ovarian Cyst 



1. Previous liistory of disca^ of 
kidneys, heart, or liver, or peritoneum. 

2. Enlargement comparatively sud- 
den. 

3. Face puffy; color waxy; early 
anemia. 

4. With patient in dorsal position 
symmetrical enlargement of abdomen, 
bulging in flanks and flat on top. 

5. With patient sitting the abdomen 
bulges below. 

6. Navel prominent and thinned. 

7. Fluctuation decided and diffuse 
throughout abdomen, but is absent in 
the highest parts. Modified on change 
of position. 

8. Intestines float on top of liquid, 
therefore i)ercu8aion gives a tympanitic 
note in the upper portions and flatness 
in the flanks when patient is on her 
back. Change in position changes po- 
sition of intestines and of resonance 
to the highest part of the abdomen. 

9. Vaginal palpation shows bulging 
into the posterior cul-de-sac. 

10. Uterus prolapsed, but size and 
mobility unchanged. 



1. No such history 

2. Gradual. 

3. Facies ovarina, anemia relatively 
late. 

4. Asynunetrical until tumor is very 
large, jxiaked on top. 

5. No change. 

6. Navel imchanged usually. 

7. Less distinct and limited to the 
cyst. Not modified by change in po- 
sition of patient. 

8. Intestines occupy same position 
all the time. No change in percussion 
with change in position of patient, i.e., 
flat over cyst and resonant above it 
and to one side, the side opposite to 
that from which the cyst sprung. 

9. No bulging into the cul-de-sac. 

10. Uterus displaced by the cyst, 
mobility limited by the tumor. 



Encysteh (m-ites^ or fluid oonfincnl to a limited part of the ab- 
dominal cavity by adhesions, may give the same areas of dullness 
and resonance as an ovarian cyst. 



3. Fibroids. — There i.s caiisi»leral>le (laiigcr of coiifui^ing a largr 
fibroiiiyouia of the utcirus wiih ii large ovarian cyst. The followuig 
table, eoiTipilt»<l from several authoi>^ ami from my o\^Tl experience, 
|M)irit8 out the cliief features in the differential duigua*?is; 



I 



iMrge Uterine Fibrmd. 

\, Menorrhagia or metrorrhagia 
roiiimoii where the growth is intersti- 
tial in part. 

2. General health not nert-ssarily im- 
paired, except aneiiiia from loss of 
blood or debility from pain* Palpita- 
tion of heart common. 

3. Barely occurs in early Ufc, 

4. Slow growth. 

5. Apt to be afiymmetricaland nodu- 
lar; tuinora commonly multiple. 

6. Consistency firm, elastic, or harcL 

7. Uterus largtj and ca\'ity enhir^t^d 
if growth is interstitial. Tumor a part 
of uterus or connected by a short and 
thick pedicle- 
s' Uterine bruit by auscultation in 

half of the cases, 

9. No cliange in facial expression un- 
less pale from hemorrhage. 

10. Superficii&l vmiis of abdomen not 
enlarged. 



Large Ovarian CyM. 

1 . Menstruation unchanged or dimin- 
ished in amount. 

2. General health iiapilied 9aafy. 
No pain exce])t in the ease d adbedcmi, 

or other compli cations. Palpitation 
uncommon. 

3. May occur in infancy. 

4. More rapid growth. 

5. Symmetrical; may be lobulated. 

6. Fluctuating. 

7. UtenLs not enlarj^eii Tumor con- 
nected with it only by ].>etUcle, which is 
apt l<i be relatively long. 



8. Absent. 

9. Facies ovarina and 
about neck and chest. 

ID. Veins enlarged. 



IpMof fie^ 



It must not be forgotten that beoaiLse of ilegenerative proo 
esBCs in a uterine fibroid then* may be fluid in the tumor antl 
fluctuation will he fr»un*l, and that in some of the ovarian tumors 
with i^olid eontents fluctuation may te absent. As stat-inl Ix'forej it 
is never ju^stifiable to tap a tumor, a proeedure once much in vogue 
for the purpose of diagnosis, Ix'eaus*/ som** of the fluiil is almost 
?*ure to escape into thi^ peritont^al cavity and to t*ause peritonitis 
of a grade and severity depending on the character and amoimt 
of fluid extrava.sated. 

4. Accumulation of Gas or Fecal Matter in the Intestines.— Tym- 
panites has Ijetm mistaken for ovarian cyst. Accnnmlatcd gas 
gives a tympanitic not4.* on percussion, the gurghng of gas in the 
bowels may be heartl by auscultation, and there is an absi?nce of 
a fluid wave on paljjation. By the vaguml touch tluTc is an 




310 



DIAGNOSIS OF DISEASES OF THE OVARIES 



af^sc^ncc! of the finn elasticity eommiinieate<l by a fluid or solid 
tumor. In the case of fecal accunuilation there is a liistory of 
chronic constipation and the distended bowel will pit on pressure 
by aljdominal or vaginal touch. Active catharsis removes the 
tumor. 

5. Fat or Tumors in the Abdominal Walls, including "Phantom 
Tumor." — ^A thick panniculus adiposus may simulate an ovarian 
tumor and, strange as it may stH^m, well-kno\\Ti surgeons have opc^- 
atcnl for tumor under such conditions. Grasping the abdominal 
walls in the hands, it is possible in most cases to determine that 
th(^ fat is in the substance of the wall rather than in the abdominal 
cavity. Edema of the abdominal walls sometimes simulates 

Central part of abdomen 
Tympanitic 




Fi«. 132. — Diagram of a Cross Section of the Abdomen of Ascites, Dorsal 

Position. 

tumor. In this case we expert to find i)itting on pressure and 
evidenc(\s of edema elsewhere*. 

Tumors of the anterior alxlorninal waDs consist of fibromyoma 
of th(^ nrtus muscle and cysts of the urachus. They are of un- 
common occurrence. 

Fibromyoma of the Rectus, — ^Two instances of this have fallen under 
my ()bs(MA^ation. Both patients w(Te twenty-nine years of age and 
moth(»rs of families. One was svvn with Dr. F. W. Johnson, of Ba^ 
ton, in consultation, March 18, 1892, and operated upon by him the 
same day in my pn^sc^nce. Here there was a tumor of soft consist- 
ency, the size of a Florida orange, in the l(^ft epigastric region. The 
other was a patient operated upon by me October 23, 1896. In 
this case tlierc* was a sonu^what smaller tumor of harder consistency 
in the right rectus muscle, just b(4()w th(* k^vel of the umbilicus. 



LARGE OVARIAN TUMORS 



311 



Both were entirely extraperitoneal and were pronoimced by the 
jiatliolugi^t ti» Ix' fil>njinyuina. 

Ct/sLs of lite urachus tlevelojf in the iiornuilly inii>ervious vord 
wliich runs from the bladder to thi* umbilicus. Like tlie bUidder 
it^If, a cyst of the itraehus represents a persi&tent portion of the 
allantoic. A cyr^ as large us the urinary bladder, or larger, may 
form in the eours<' of the iiraehu^. Such a eyst is situated Ix'twtvn 
the fascia and the perituneum on the insitle of the aUlomiiial 
parietes, in the median line. It is to be differentiated from an 
ovarian cyst by its absence of coruif*elion with the uterus or its 
ap|K^ndaget^, by the greater area in the abdomen of, intestinal 



Formerlj dull, 
now cympanitJc 




Fig, 133. — ^The Same as Fig, 132. Lateral Position, Showing Change in Situation 
of Areas of Dulbics^s and Tympany. 

rc*sonance, and b)^ tlie aliscnce of the other signs and ?*}Tnptoms 
of ovarian cyst. 

** Phantom Twmor. "^Pliant om tumor occurs occasionally in 
hyj^erical women who have the jiower of contracting the nmsclt^s 
of the alxlonien so as to farm a mass lliat simulates an alKjominal 
tumor. The muscular contraction can be overcome f^rnetim(»« 
in the^e ca>^es by firm pri^ssure of the hands and the tumor then 
disapix-ai-s. There is exaggerated tympany over the tumor Ix^ 
cause the intestines, helrl by t!ie mujsclea, form the tumor. In 
many cases it is impossible to make an exact diagnosis without 
etherization, and accordingly it is well to etherize a doubtful case 
of phantom tumor or tumor in the alKlnniinat wall. 

6. Cyst of the Pancreas, — ^The situation of the tumor is of great 
importance in dili'(*rentiating cyst of the |)anereas from ovarian 
cyst. The fonner develops luxler tlie margin of the ribri on the left 




312 DIAGNOSIS OF DISE.\SES OF THE OVARIES 

side and grows from above downward. If the cyst is large the 
liver and stomach may be displaced upward, while the transverse 
colon is depressed under the tumor, the cyst reaching the pelvis 
only exceptionally in the case of very large tumors. Therefore a 
pancreatic cyst can be confused only with high-lying ovarian cyst. 
Pancreatic cysts generally are thin-walled and the fluid is thui, 
consequently fluctuation is marked. The greatest convexity of 
the abdomen is in the neighborhood of the umbilicus. The history 
given by the patient is that the tumor was high up under the ribs 
when first noticed, and bimanual examination of the pelvic organs 
shows that there is no connection between the uterus and the 
tumor and that the ovaries are not enlarged. 

7. Tumors of the Spleen, Liver, and Kidneys. — Tumors of the spleen 
originate, of course, in the left hypochondrium, have an oblique posi- 
tion, and a peculiar elastic consistency. Under the influence of de- 
generative processes or the presence of an echinococcus cyst there 
may be fluid in a splenic tumor. Such a condition must be re- 
garded as very unusual, however. In the case of uxmdering spleen 
the tumor may be in the iliac fossa, and may be mistaken for an 
ovarian tumor or a kidney. Careful palpation of such a tumor 
with the aid of an anesthetic will show one or more notches in the 
anterior border and perhaps a vertical slit at the hilum. Palpa- 
tion of the kidney regions will show the presence of the kidneys 
in their normal situation. It has been suggested by H. A. Kelly 
(Kelly and Noble, *^ Gynecology and Abdominal Surgery,'' Vol. II., 
p. 597) that by passing a renal catheter and injecting the kidney 
with enough fluid to produce a mild renal coUc, the pain will be re- 
ferred to the lumbar region and not to the splenic tumor. Exami- 
nation of the pelvic organs ought to exclude uterus, tubes, and 
ovaries from participation in the tumor. A wandering spleen has 
been knowTi to become lodged in the pelvis and there to obstruct 
the intestine (case of Korte, cit(Ml by J. Bland-Sutton, Brit. Med, 
Jour,, 1897, p. 132), and J. C. Webster {Jour. Avier, Med, Asso,, 
1903, Vol. XL., p. 887) has reported a case of wandering spleen 
that occupied the right iliac fossa. 

Tumors of the liver may be confused with ovarian tumors if 
they reach do^\^lward to the pehis, or if during late pregnancy 
an ovarian tumor has become fixed to the liver by adhesions, so 
that upon involution of the uterus the tumor remains in the upper 



LARHE OVARIAN TUMORS 



313 



ul>lniiirn, Tlir lirru, hard eonsisteney of llic liver is more or less 
eharacteristic, also its sharp lower Ijordtvr, which is plaetnl obliiiuely 
to the ensiform cartilage and is indented witli a notch for the gall 
blailder. Also, all liver tumors move more or less on deep respira- 
tion, except acceasory lobes^ very large tumors, and echinococcus 
disease. The peKic oi-gans are investigates! and the relation of 
the tumor to the liver tested by moving the tumor atx)ut and 
noticing if the liver is moved also. 

Tumors of the kidney are not of frequent occurrence. The most 
common are: hypeniephroma and {lapilkr}^ cystoma. Malignant 
timiors afl'eet especially the yomig and the old. Heinatmia is 
present in almost all malignant tumors of the kidney; pain in the 
region of the kidney is a less common symptom. Hypernephroma 
is a tumor arising from adrenal tissue but involving the kidney in 
practically ah instances. The tumor is lobulated and extends 
toward the metlian line. It is malignant and has metastases, 
most commonly in thi^ lungs and liver, ' 

Polycystic duea^sie of tlie kidney consists of a cystic degeneration 
of the kidney parenchyma, and the tumor is like a bunch of grapes. 
Many of these tumors are congenital O^ngenital kidney disease 
is apt to be associated mih tlisease of the ovaries, as the two de- 
velop together in fetal life. Ecliinococcus cysts develop in the 
kidney in 5.8 per cent of all cases of hydatid diseases The tumor 
grows slowly and f<;>rms a smooth, roimd, movable nm.ss. 

A movable kidney may get as low as the p<:J\is. Its sha{x* is 
characteristic. Hydronephrasis may accompany renal tumor and 
in this case the urine will show abnormal constituents. 

Cydic tumors or simple eyst.^ of iJte kidney arise* m the outer part of 
the cortex, and may attain great size. Such a cyst is to be diffti*en- 
tiateil from an ovarian cyst by its kx-ation in the flank, its relative 
inunobilityj and by its not Ixing connected witli the uterine organs 
as i>rov*Hl by the bimanual <*xamination. If the uterine organs are 
normal the difTfTcntiation is easier than if they are tUsc^ased. 

8. Cyst of the Omentum. — t'ysts of the omentum are mostly flat 
and sliield-sha|)ed; they are very freely movable, and can he ro- 
tattnJ Si:» that in some cases the fjosterior jxirtion of the cyst may 
l3e palpatiMJ. They arc of infrecjucnt occurrence, and it is gener- 
ally easy to determine that the cyst has no connection with the 
uterine oi^gans. 



J 



314 DIAGNOSIS OF DISK4SES OF THE OVARIES 

9. Echinococcus Cysts. — Echiiiococcus disease may be confused 
with ovarian tumor especially if it involves structures in the p(»lvis. 
It has been referred to as occurring in the liver, spleen, and kid- 
neys. In the pelvis it occurs in the following situations according 
to Bland-Sutton ("Diseases of Women,'' Bland-Sutton and Giles, 
p. 388): (a) The uterus; (6) the mesometrium; (c) the pelvic bones; 
(d) the omentum; (e) the Fallopian tubes. There is no authentic 
case on record of primary echinococcus cyst of the ovaiy. Large 
tumors may develop in any of the structures named. As a rule, 
they form part of a general invasion of the subperitoneal tissues. 
The colonies are apt to communicate with the vagina, bladder, or 
rectum and the characteristic vesicles escape with the urine or feces. 
Bland-Sutton says, "The clinical recognition of echinococcus cysts 
in the pelvic organs, mesometrium, or bones is sometimes made by 
a sort of 'lucky guess' when other and more conmion diseases can 
with certainty be excluded. Occasionally when a patient seeks 
advice for pelvic trouble, and brings ' vesicles ' which have escaped 
by the rectum, vagina, or urethra, much speculation is spared. 
When the bones are eroded and swellings form under the skin, 
they are punctured, and characteristic fluid with vesicles and 
booklets escapes, and so the diagnosis is established. When the 
cysts suppurate the physical signs are those of abscess." 

10. Dilated Stomach. — Careful percussion of the stomach area, 
auscultation of the abdomen while the patient swallows a mouth- 
ful of water, the appreciation of a gurgling sound all over the region 
occupied by the stomach, and the situation of the maximum of 
enlargement of the abdomen above the umbilicus, ought to deter- 
mine the presence of a dilated stomach. If there is a doubt ad- 
minister an effervescent mixture and practice percussion when the 
stomach is distended with gas. 

11. Distended Urinary Bladder. — ^The bladder may rise as high 
as the umbilicus when overdistended and may present the appear- 
ance of an ovarian cyst. (Sec Fig. 85, page 217.) The bladder 
tumor is in the median line, close held to the back of the arch of 
the pubes; it bulges into the vagina, distending the anterior wall; 
thcTe is almost continuous ovctHow of urine, and generally hypo- 
gastric distress, except where the patient is unconscious or the 
distention has existed a long ium\ Passing the catheter removes 
all doubt. 



rOMPLK^ATIONS OF OVARTAN TUMORS 



315 



Diagnosis ok thi: (*oMPLi<^\TitjNs of Ovarian Tltmors 



The rniiiplirations to wliii-h ovarian tumors an* sul)jcM't an* 



L 
2, 

3. 



Adlicsittns and inearcfTation. 

Intraligamentous development. 

T<jrNitin of the iietlifle, 
4, Inflect ion antl .suppuration, 
.1 Degenerative processes, including malignancy* 

6. Rupture, 

7. A-^sofiation with pretjjnancy. 
I. Adhesions and Incarceration, — Adhesions Iw^tween an ovarian 

tumor and its surroimding structures makr the dia^^nosis much 
more difficult, especially in the ca.se of small ovarinn tumors, thoR^ 
lying wholly within the cavity of the p<_4vis. The history of at- 
tacks of inflammation may give a clew to the presence of adhesions, 
a^ the occiiriTnce of pain. It is a w<»ll-known fact that the parietal 
peritoneum rather than tlie visceral |RTitoneum is the s<^at of 
pain. This fact has Ixtu dernonstrated during alKJominal opera- 
tions performed under local anesthesia. Tlirrfi(»re we should 
expert adhesions to the parietal jn'ritoneum to cause niore jjain 
than those to the viscera. Extensi\x* adhesions nmy occur with- 
out any pain whatsoever. 

Fixation of a tumor to a greater or less degr^^:* intlieates adhesions 
8S a rule. The* exception is the ran* condition of in4:arceraium 
'Witlund udhesioHs, A tumor may Ix'eome incarcerated in the 
pelvis, thus causing obstruction of the bowx-l, or abortion as in the 
ease of the retroflexetl prr^gnant uterus. 

An attempt should tie nia<le to dislotlge an ovarian tumor fixed 
in the pc4vis, by i>utting the ])atient in the knt^e-chest position, 
letting air info the vagina by means of the Sims speculum, and by 
making traction on the cervix with a tenaculum. I'pward |iressyre 
on the tumor, tlie patir^nt Ix'ing in the dorsal |)osition, through 
cither the vagina or rectum will, in many cases, itislodge a non- 
adherent tumor. After reposition the bimamia! pal] ration and the 
n»ai>pmg out of the piMlieli' jiroctHnl with greater facility, Somt^ 
times the shape and character of adhesions in the jxlvis can be 
■ made out by touch, also adhi^sions to the afnlominal walls In the 
I cai?e of large tumors can be detennuietl in a smaller proportion of 



I 



316 DIAGNOSIS OF DISEASES OF THE OVARIES 

cases. Adhesions to the intestines, omentum, liver, or spleen can 
not hvt diagnosed with eertainty. 

2. Intraligamentous Development. — If a tumor has grown between 
the layers of the broad ligament it is immovable and can not be 
displaced into the abdominal cavity by bimanual manipulation. 
It gives the impression of being closely unitetl with the uterus and 
the examiner may receive the impression that he has to do with a 
fibroid tumor of the uterus. Intraligamentous tumors are gen- 
erally cystic, however; they have no pedicle and sometimes may 
be diflferentiated from parovarian cysts by this characteristic. 

If the physician can decide that an immovable cystic tumor in 
the pelvis is connected not only with the uterus but with Uie side 




Fia. 134. — Diagram Showing the Course of the Utero-sacral Ligaments in the 
Case of a Retro-peritoneal Tmnor. 

of the uterus the tumor is probably an intraligamentous ovarian 
cyst. This may be done sometimes by grasping the uterus and 
palpating it separately from the tumor. The uterus is commonly 
displaced laterally to the side of the pelvis opposite to that 
occupied by the tumor. Occasionally the ovary with its long 
Fallopian tube stretching to it as a cord may be made out lying 
on the top of the tumor, and now and then the round ligament 
can be palpated as a round cord coming over the surface of the 
tumor to the internal abdominal ring. 

To distinguish a tumor developing under the peritoneum in the 
back of the p(;lvis from an intraligamentous tumor one tries to 
palpate the utero-sacral ligaments. If these are in front of the 
tumor it is a retro-peritoneal growth, whereas if the ligaments 



COMPLICATIONS OF 0V.4JltAN TUMOILS 



317 



arc bfhiod the tuiDor it is an intraligamentous neoplasm. (Sec 
Figh5. 134 and 135.) 

3, Torsion of the Pedicle, — Rotation of an ovarian tumor on it.s 
long axifi causing twisting of its jj<niii'Ie 18 l)y no moans an uncom- 
mon ha(jpening. It pre^supfX)«es the absence of ailhe^ions to sur- 
rounding fixetl structures such as the pelvic walls or the pariete.s 
of the ahlomen. It is more apt to occur in tumors of meiliuni size. 
To ileteet a twisting by palliation of the jHjiliele wlicre all the con- 
ditions are most favorable is a possibility. Ordinarily torsion is 
diagnosed only by its results. The twisting may be gradual, in 
wliieh ease the tumor adjusts itself to the lessened blootl supply 
caused by the constriotion of its jxidicle, or it may be rapid. 




Fig, 135, — Diagram Showing the Course of the Utero-sacral LigameDts in the 
Caae uf an Intra-llg^meiitoua Tumor, 

WTiether gradual or rapid there comes a time when the blond supply 
is cut off, then ensue in the cyst eilema,enlargeuient, supimration, 
or even gangrene. Atrophy lias Ix'cn known to oceur in the ease 
of very small tumors and eon)i>Iete separation of the cyst from its 
pt^dicle in rare instances. Torsion is apt to be followed by adhe- 
Bions, eti^peciall}^ adhesions to the towels. 

Syniptoms of the elironie stage of toi-sion may bt* entirety want- 
ing, or a patient may complain of pains in the abrlomen especiaDy 
at the time of the eatanienia when congestion of thr jx^lvie organs 
LK normally great^^st. These jmins may t>t* associated witli nausea 
and vomiting and are apt to follow violt^ut t*xertion or trauma. If 
the testing is sufficient to cause blood stasis the sjTiiptoms are 
those of general peritonitis and there is pi*csent an acute abdominal 



J 



318 DIAGNOSIS OF DISEASES OF THE OVARIES 

emergency. Acute abdominal pain, rapid, feeble pulse, vomiting, 
elevation of temperature, and a rigid abdomen occurring in a woman 
known to have an ovarian tumor are symptoms calling for im- 
mediate operation. 

Twisting of a pedicle of an ovarian tumor has been mistaken 
for appendicitis. Bimanual examination will reveal the presence 
of the ovarian tumor; the pain caused by torsion is not of the colicky 
character of the pain of appendicitis. Finally the history reveals 
no similar attacks of pain and no history of digestive disturbances 
and irregularity of the bowels as in the case of appendicitis. 

4. Infection and Suppuration. — Infection of ovarian tumors with 
streptococcus, typhoid bacillus, or bacterium coli communis, is 
transmitted by the blood current, or from the intestine, urinarj' 
bladder, or the Fallopian tube. Formerly, when it was the custom 
to tap ovarian cystomata, infection was introduced very frequently 
in this way. Ovarian cysts become infected following an attack 
of typhoid fever, and in this case the bacilli, in all probability, gain 
entrance through the blood. A patient known to have an ovarian 
cyst should be watched carefully for evidence of infection of the cyst 
following an attack of typhoid fever. The symptoms are chills, 
elevation of temperature, rapid pulse, pain, and tenderness in the 
abdomen. 

The Fallopian tube is a very frequent carrier of infection to an 
ovarian tumor. This is to be inferred because it is about the 
fimbriated end of the Fallopian tube that the densest adhesions 
are to l)c found during operation for the removal of infected cysts. 
It is probable that infection following puerperal fever reaches a 
tumor by this channel. In the case of an inflamed bladder or in- 
testine or veiTTiiform appendix the organ may become adherent 
to a tumor and the inflammatory process be carried to the growth 
l)y continuity. The inflammatory process, however transmitted, 
may go on to mppuration. In this case there are to be noted 
sudden enlargement of the cyst, severe pain and tenderness, rapid 
and weak pulse, and chills, high temperature, and exhaustion. 
Prompt operation alone will prevent rui)ture or general peritonitis 
and death. Gas may Ix? fonned in the cyst and then a tympanitic 
note will be given to the i)ercussion over it. 

5. Degenerative Processes Including Malignancy. — ^The following 
secondary changes may take place in an ovarian tumor, although 



none of them can be diagnosed with certainty. On account of the 
necessity of speedy operation inilications of malignancy require 
special attention, however. 

(a) Calcareous degeneration. 

(6) Fatty degeneration. 

(c) M>^oniatouB degeneration. 

(fl) Changes in the Huid eontrnts from Mraw color — with 8|>ecific 
gra\Hty of from 1010 to IO^jO — to thick or semisolid, of various 
colors and consistencies. 

(e) Malignant degeneration. Carcinoma, sarcoma, endothe- 
lioma, and teratoma are the malignant processes affecting ovarian 
tumors. Suspicion of malignity attaches to double-sided tumors. 
I.e., tumors of both ovaries, and to paitial development in the 
broad ligament. A*?eites is common in the case of malignant 
tumors, and Ls apt to be small in amount except in the late stage's 
of the disease. Malignant tumors, except sarcoma, are most apt 
to occur in old rather than in young women, and cachexia is found 
in the later stages only. Early edema of the legs in the case of small 
tumo!"s is said to be a sign of mahgnanc\\ When the disease has 
attacked the surface of the tumor hardness of the tissues anfl a 
nodular feeling by both aljdominal and vaginal palpation is most 
charaet<»ristic. The noilules or lumps may i>e large or small. 
The surface is irregular. It should not be forgotten that cancer 
of the ovaries is very often metastatic and that the primary seat 
of the disease should Ix' sought in the stomach or intestine. 

6. Rupture.^ — Rupture of an ovarian cyst is of unusual occurrence, 
especially in these days of relatively early operation on women 
who have tumors. In the older, preaseptic days, when tlie danger 
of operation was great, many cysts ruptiu-ed and filled again or 
caused peritonitis as it happened The physician and also the 
niu'se should rememlxT that a thin-waDed cyst or one having weak 
places in its walls iK'cause of degenerative processes may Im? rup- 
tured by a too vigorous bimanual examination or by preparations 
for an abdominal o{>eration. Both of these accidents have occurred 
in my expf^'ii'nce. In the case of a mullilocular cyst only one 
loculus may rupture and the rupture may Ix^ into the main cyst 
cavity, into anotlni' ]o(*ulus, or into any one of the following struc- 
tures: peritoneal cavity — most frequent — and bladder, vagjna, or 
rectum. Rart^ly rui>ture has occurred into the small intestine, or 






320 DIAGNOSIS OF DISEASES OF THE OVARIES 

Fallopian tube, and very rarely through the abdommal wall or into 
the stomach. The causes of rupture are, degenerations of the cyst 
wall; papillomatous growths penetrating the wall; torsion of the 
pedicle, causing hemorrhage or suppuration in the cyst with in- 
creased tension ; and trauma, such as blows on the abdomen, care- 
less handling, already referred to, or contractions of the abdominal 
walls in labor. Parovarian cysts when once ruptured may not 
refill. In the case of ovarian cysts the wall continues to secrete 
fluid after rupture and the cyst may refill or the fluid may be 
'poured into the organ into which the openmg has been made. 
If the fluid is clear and serous it may cause little irritation of the 
peritoneum ; if, on the other hand, it is colloid or dermoid in char- 
acter it is apt to set up a lively peritonitis. The gravity of rupture 
depends then, in large measure, on the character of the cyst con- 
tents. This being unknown, the complication must be regarded 
as serious and treated by inmiediate operation, for rupture of an 
infected cyst into the peritoneal cavity is usually fatal. 

The symptoms are severe pain in the abdomen, faintness, rapid 
pulse, perhaps subnormal temperature. Examination shows ab- 
sence of the tumor and free fluid in the peritoneum, or discharge of 
fluid from bladder, vagina, or rectum, or other viscus. If only one 
loculus has been ruptured the tumor wall be diminished in size 
only by so much. 

7. Association with Pregnancy. — Small or medium-sized tumors 
are more often found in association with pregnancy. Because of 
the danger of rupture and torsion of the pedicle, the diagnosis 
of pregnancy in these cases is of the greatest importance. In the 
early months it is a question of determining the presence of more 
than one growth in the pelvis or a tumor on each side, one being the 
uterus and the other the ovarian tumor. The signs of pregnancy 
are referred to in Chapter XXII., p. 420. If physicians would 
make it a rule to examine all pregnant women under their care 
from time to time with reference to the detection of tumors and 
other abnormalities, many of the tragedies of the puerperium 
would be avoided. In cas(*s of doubt it is advisable to administer 
ether in order to make a diagnosis. 



PATIlOLOniC AL VARIETIES OF OVARLVN TUMOR.S 



32 i 



I 



I 



'Diagnosis of thk Different Pathological Varieties op 

OVAKIAN TUMOBS 

The <liffcrcnt kinds of ovarian tuniom according to their patho- 
logical rhamet prist ics5 are shown in tlie lint on page 29L Prognosis 
and treatnit'nt depend in a measure on the kintl of tumor present; 
theR^fore, certain probabilitie^s may be stated sis to the different 
tumors. The following description is taken with few changes 
from Winter's^ **G>iiaekologi.schen Diagnostik," p, 303. 

I* Follicular cysts never occur largei* than a base-l.>all. They arc 
unilocular, have thin walls^ and arc not tightly distended, so that 
fluctuation can be eheited easily* They are generally unilati^ral 
and do not cause fjain. 

2* Cysts of the corpus luteum are not larger than a base-bail; they 
have thick walls, and are unilateral. 

3, Simple cysts have tliin wall^ and tliin fluid contentsp and are 
differentiated cUnically from follicular cysts only by their greater 
size. 

4, Multilocxilar cysts are the most common kind of ovarian 
tumors. They vary m hizq from verj^ small to enormoiLs. In the 
Ix^ginning t?[Uch a tumor is roimd, but Ix'eome^ irregular in shape 
by the development of several cysts within the parent cyst. There- 
fore, the surface becomes lobulated and in some eases the large 
and small daughter cysts can Ix^ palliated. The consistency 
varies according to the fluid contents. Hard portions are apt to 
be found in the walls where there has been no cystic degeneration. 
The small or multiloeular tumors are fairly movable; the larger 
ones are hmite<l in motion by adhesions, which are common, 
especially to the omentum, bowel, and abdominal wall, seldom to 
the uterus or other iH'hie organs. These tumors are usually uni- 
lateral and have a well-marked pedicle. Ascites is generally absent ; 
when presc*nt it is in small amonut. 

5, Proliferating papillary cysts are seldom larger than a man's 
head. They are not often perfectly round in shajX' and have an 
uneven, lumpy surface. In the situations where the papillary 
masses occur the consistency is not so fluid as elsewhere. The 
tumors are ajxt to affect Ijoth ovaries — iloublc tumor: they are of 
intraligamentous development, at least on one side, and are often 

21 



322 DIAGNOSIS OF DISEASES OF THE OVARIES 

partially, but not entirely, in the broad ligament. When the 
papillary masses have pierced the wall of the tumor there are 
metastases in different parts of the abdomen, especially in Doug- 
las' cul-de-sac. Ascites is common. 

6. Primary carcinoma, when small, retains the form of the ovary; 
when large, the tumor has a surface that is very rough because of 
knobs and excrescences. Small tumors are hard, large ones are 
cystic because of degenerative processes inside. The pedicle is 
for the most part short, and the tumor may be intraligamentous. 
The tumors are generally double and ascites is commonly present. 
Early edema of the legs is to be looked for in the case of small 
tumors, and cachexia in the late stages. Metastases occur early. 
Secondary carcinoma attackmg a cyst has the same charact(*ristics. 

7. Dermoids are seldom larger than a man's head and most often 
between a hen's egg and a Florida orange in size. They are round 
and oval in shape and are seldom double, having for contents 
thick fluid, fat, bone, and hair; fluctuation is not marked. Some- 
times bone may be felt in the wall of the cyst, and often there are 
portions of solid tissue in dermoid cysts. These cysts are of slow 
development and occur most often in young persons. Adhesioius 
are common and occasionally the tumor adheres so closely to the 
intestine that there is gas in the tumor. The x-rays may show 
the bone in a tumor. 

8. Teratomata are apt to be the size of a man's head and occur 
mostly in young subjects. Their consistency is solid, often hard, 
and they may contain nodules of varying consistency. If the 
tumor is malignant there are metastases and ascites. The clinical 
diagnosis can seldom be made. 

9. Fibroma of the ovary is a round or oval tumor, very hard, 
with smooth surface and generally unilateral. It may be as large 
as a man's head and ascites is usually present. Of ton cystic cavi- 
ties develop in such tumors, and the ascites does not return after 
the tumor has been removed. Fibroma can not be distinguished 
clinically from fibrosarcoma. 

10. Sarcoma of the ovary occurs sis fibrosarcoma (spindle-celled 
sarcoma) and as round-celled sarcoma. The former is generally 
double, has a smooth surface and a hard consistency, and ascites 
is present. It is benign, and no metastases are formed. The 
round-celled sarcoma, on the other hand, occurs as a soft, medullary 



PATHOLOGICAL VARIETIES OF OVARIAN TUMORS 323 

tumor with tolerably smooth surface. It is generally unilateral 
and ascites is often present and the tumor may be of considerable 
size. The tumor elements perforate the surface early and in- 
filtrate the neighboring organs, especially the abdominal cavity. 
II. Peri- and endothelioma have the same characteristics as 
round-celled sarcoma. 



CHAPTER XVIII 

THE DIAGNOSIS OF DISEASES OF THE FALLOPIAN TUBES 

Anatomy and age changes, p. 324. 

Congenital Anomalies, p. 32(5 : Absence of the tubes, p. 326. Accessory 
tubes and ostia, p. 326. Diverticula from the tube, p. 326. Hernia of the 
tube, p. 326. Displacement and elongation of the tube, p. 326. Cyst of 
Morgagni, p. 327. 

Salpingitis, p. 327: Acute, p. 327. Chronic, p. 329. Gonorrheal, p. 330 
Tuberculous, p. 330. Actinomycotic, p. 332. Echinococcus infection, p 
332. Syphilitic, p. 332. 

Retention tumors (Sactosalpinx), p. 332. Pyosalpinx, p. 332. Hydro 
salpinx, p. 333. Hematosalpinx, p. 334. Diagnosis of Sactosalpinx, p. 335 

Differential diagnosis of Apjiendicitis and Salpingitis, p. 336. 

New Growths, p. 337 : Polypus, p. 337. Papilloma, p. 337. Embryoma 
p. 338. Myoma and fibroma, [). 338. Fibromyxoma, p. 338. Carcinoma 
p. 338. Sarcoma, p. 339. Chorioepithelioma, p. 339. 

ANATOMY AND AGE CHANGES 

The Fallopian tubes are (leveloptnl from the portion of Miiller's 
ducts lying above the round ligaments, and as they come from the 
same structures as the uterus and vagina they are continuous with 
these organs and tluur canals, and are parts of one long tube, 
branching, when it reaches the uterine horns, into two tubes. (See 
Fig. 71, page 198.) 

Each tulx3 occupies th(^ free border of the broad ligament. It 
has an average length of four inches (10 centimeters) but may 
vary; sonujtimes one tub(* is longer than its fellow. The inner 
third of the tub^ is narrow and is from one-sixteenth to one-eighth 
inch (2 to 4 millimeters) in diameter; it is called the isthmus. The 
outer two-thirds is larger in diameter, three-eighths inch (7 to 8 
millimet(Ts), is called the ampulla, and ends in the infundibulujny 
or trumpet-shaped depression, in the center of which is the ostium 
alydominale surroundcnl by the fimhricv, or fringes. These fringes 
an^ (*xt(»nsions of the reduj)licated mucous membrane lining the 
tube and are of uneven length. Running from the abdominal 

324 



ANATOMY AND AGE CHANGES 



325 



n^tiuni to l!iu ovary is tiu* luf>f)-ovarian ligament, traversal by a 
fun'ow so tliat it appears to Im^ a Icmg ftnil)riiL Hiis lypresents 
the uppenriost ]tortion of Miillcr^s duct that has hixm opcnoil out, 
liLsteacl of remaining!; a^ a flost'tl tulx*. The tii)>c is cr^nvokitetl, 
tlie isthmus Is directed outward and j;Ughtly upward, while the 
ampulla arches over anil descends, so that the infundiluikim m 
direet-eil toward the ovary and the fimbria' are in contact with that 
gland. (See Fig, 1 16, p. 285.) 

The lumen of the tube varies from the diameter of a bristle at 
the isthmus to a fjuarter of an inch (some 5 niillimetei's) in the 
ampulla. It is lined with nmcous membrane^ and covered with 
columnar ciliated epithelium, which is redupHcated and throwTi 
into longitudinal folds. These folds become thicker as they a{> 
proac*h the infundibulum an<l on the alKlomiiial side of the ostium 
are continuous with the finJbriu^ The tuk>c is composed of un- 
striptnl iiiuselt* filx^r, continuous with tliat of the uterus, and ar- 
rangeil in an outer longitudinal layer and an inner circular layer. 
Outside the longituchnal layer is loose connective tissue bc^tweeii 
it and the {jt^ritoneum, which covers two-thirds of the circumfer- 
ence of the tulx^ and is terminated by a sharp t^dge at the ostium 
alMlominalt\ 

The functi^m of the tutjes is to carry the ova to the uterus. It 
has been shown by Hofmc^ier and Mandl (J. Wliitridge Williams, 
**ChTiecology and Alxlominal Surgery," Kelly and Noble, Vol. II , 
p. 132) that there is a current of fluid from the {>eritoneum, or 
secretion from the tubal mucosa, jiromoted by the eilia of the tuljal 
epithehal cells, from the ablominal ostium of the tubc^ to the 
internal o*; of the uterus. It has been proved by experiments on 
animals and a few ol]»servations on hmnan l>eings that a few hours 
after coitus spermatozoa can lie found in the outer portions of the 
tMlx\s and even on tht^ ovaries, so that it wouhl ap|*ear that the 
siM^rmatozoa get into the tubes in spite of the current against them, 
and that the tuln' is the rmrmal place of inipregnaiion ratlier than 
the uterus. Under normal conditions the fertilizcnl ovum is passfnl 
along by the cilia to ihr uterus where it l>ecomes end>e(lded in the 
uterine mucosa. Under aluiormal conditions it is arrested in the 
tulx^ and a tuba! pregnancy results. 

At the menopause the Fallo])ian tubes atrophy, becoming shorter 
and narrower and the ejnthelial elements disappear, so that in the 



326 DISEASES OF THE FALLOPIAN TUBES 

old woman they arc nothing but slender cords, often having no 
lumen. (See Fig. 119, p. 289.) 

CONGENITAL ANOMALIES 

Absence. — Complete absence of both tubes is exceedingly rare 
and occurs only in connection with failure or rudimentary develoi>- 
ment of the uterus. Absence of one tube is found in cases of failure 
of development of the corresponding uterine horn. Partial de- 
velopment of the tube is more comman than complete absence, the 
tube bemg represented by a narrow, impervious cord, or a portion 
of the tube only may be implicated, and the isthmus may be normal 
while the ampulla is undeveloped or atypical, or vice versa. The 
diagnosis can not be made without an abdominal operation. 

Accessory tubes have been described not infrequently. Probably 
many of them are not true cases of extra tubes but accessory ostia, 
a much more common condition. Three reporters at least have 
given instances of true double tubes, and Nagel (Veit's " Handbuch," 
Bd. I.) found a double Miillerian duct in a human embryo. 

Accessory ampullae communicate with the main lumen of the 
tube, usually entering near the attachment of the mesosalpinx. 
Each has its own infundibulum and fimbriae. As many as six 
accessory ostia have been reported; one or two are not uncommon. 

Diverticula of the walls of the tube appearing as hemiae occur 
occasionally, and, like the supernumerary ostia, are of importance 
because they may be lodging-places for fertilized ova, and thus a 
cause of tubal pregnancy. This anomaly, as also the preceding, 
can not be diagnosed except at operation. 

Hernia. — The tube is found sometimes with the ovary in a hernial 
sac. Such hemiae are generally of the inguinal variety and uni- 
lateral. The condition is not susceptible of diagnosis before opera- 
tion. 

Displacement and elongation of the tube may be congenital or 
acquired. The tube is displaced to a greater or less degree with 
displacements of the ovary and uterus, and also, in the case of large 
ovarian tumors and large tumors of the broad ligament, it is both 
displaced and elongated. In pregnancy it becomes lengthened 
enormously as the uterus approaches its size at full term and after 
labor the tube involutes with the utcTiLs to regain its normal size. 



S.AXPmOITIS 



327 



Sometimes, where the conditions for examination are most 
favoral^le, i.e,, very tliin abdominal walls or separation of the recti, 
it 18 potssible to pa!i)att' an ehmgated Fallopian tubi* coursing over 
a timior or at the side of a jjregnant uterus. Generally the iliagnosi^^ 
can not be made. 

The cyst or hydatid of Morgagni is a .small cyst rarely larger tlian 
a pea, attached l)y a stalk one to one and a half inches (some 2 to 6 
centinieterH) long, to the findjriie or to the tulxi itself. It is en- 
tirely harmlesss and ha no clinical importance. 



SALPINGITIS 



Salpingitis is the chief disease of the Fallopian tubes of interest 
to the practising physician. 

The classifieation of salpingitis from an etiological standpoint is 
difficult becaase it is impossible to di.stinguish the different sorts of 
bacteria tliat serve as excitmg causes. The streptococcus and the 
gonococcus are the two most important microorganisms. It ia 
probable that in those cases where the pus in the tubes is ster- 
ile the inflammation was originally of streptococcic origin but 
that the organism has ditnl out, These organisms are transmitted 
to the tubes through the uterus, an endometritis being an almost 
invariable precursor of a salpingitis. The tulx-rcle bacillus is a not 
infrequent cau^e of salpingitis, and rare causes are actinomycosis, 
ecliinoeoccus tUsease, and sji>liilis. Hennirrhagic salpingitis may 
accompany the exanthemata, and there is a mild catarrhal form of 
salphigitis and fuTisalpingitis of imknown origin tliat occurs as a 
compUcation of uterine tumors. 

It is possible for fluiils injected into the uttTUs to pass into the 

tuljes, especially when the tubes have Ix»en hypertrophied by 

pregnancy and when the normal tonus is not present^ and thus set 

up a salj>ingitis, though this is an aeatiemic affair. The hnnen of 

the isthmus of the tube ia very small and the irritation caused by 

foreign fluids Si*ts up a contraction of the circular fibers so that it is 

_ seldom that fluid can be madi' to [>ass through, 

I Salpingitis may \}q divided cliiucally mto acute and chronic, 

■ Acute Salpingitis, — Pathology. — In the case of catarrhal sdpi'mjiti^f 

m in the c^rly stages of an acute attack the mucou>s membrane is 



328 DISE.\SES OF THE FALLOPIAN TUBES 

swollen so that the redundant foI(k fill the lumen of the tube. The 
muscular and peritoneal coats are involved to a greater or less 
degree and the entire tube Is re<ldened; the tissues are edematous 
and soft. According to the character of the infecting agent the 
inflammator\' process extends or does not to the ovary and neigh- 
boring structures of the peritoneum through the ostium abdom- 
inale. Apparently sometimes the swelUng of the mucosa in the 
tube is sufficient to close the ostium and^ the disease is limited to 
the tube itself. In the tube accumulates a certain amount of serous 
fluid, drainage into the uterus being interfered with by the swelling 
of the mucosa in a very small canal. 

In the ca.*5e of pundeni salpingitis all the processes are intensified. 
The mucous membrane is more swollen and injected; the entire 
tube is much enlarged and there is pus in its canal. The peritoneal 
covering of the tube is involved, and, either by direct extension of 
the inflammation through the wall of the tube, or because of the 
action of the pus that escai)es from the ostium of the tube, ad- 
hesions of the ampulla to surrounding structures, — bowel, omen- 
tum, bladder, or uterus, are formed. The mesosalpinx and broad 
ligament are infiltrated so that they have a board-like feeling. 

Symptoms. — The symptoms of acute caiarrhal salpingitis are so 
slight that they are overshadowed by the symptoms of the co- 
existing endometritis. (See page 174.) The symptoms of acute 
purulent salpingitis^ on the other hand, are often severe, consisting 
of abdominal pain, fever, rapid pulse, uterine hemorrhage, dysuria 
and painful defecation, and purulent vaginal discharge. Accord- 
ing to the amount of localized peritonitis are the symptoms more 
urgent. Where the inf(»ction involves the ovary and a tubo- 
ovarian abscess results the symptoms and signs are those of pelvic 
abscess. (See page 193.) 

Diagnosis. — The history is that of endometritis (see page 174) 
and preceding infection. In the catarrlial form palpation by the 
bimanual touch may reveal tenderness of the tube, but this is a 
fine point in diagnosis. In the purulent form, not only tenderness 
but thickening of the tube may be evident. It is especially to be 
cautioned that the utmost gentleness be used because of the danger 
of expressing pus from the ostium of the tube into the peritoneal 
cavity. 

Evidences of endometritis are also present. If there is much 



SALPINGITIS 



329 



distention of the tube in the subacute stage the tute may be nnukt 
out as a sausage-, €lul>-, or rctort-shapeil botly, and it is apt tu Ix' 
in the cul-de-sac of Douglas. (See Pyosalpinx.) Acute purulent 
salpinp:iti8 is a very coninion affection and the attempt should be 
made to diapK>8e the <Hsea.se early in its course. 

Chronic Salpingitis. — Pathology.— Chromv stdjiingitis results from 
an acute sal|migitis. The tulx^ h usually closely adherent to the 
ovary and surrounding structures; it is ajit to be in the eul-tle-sac 
of Douglas; it shows markeil convolutions and twists. The walls 
of the tube are generally thickcnetl and indurate<l. Sometimes 
the thickening is in the isthmus, and at others in the ampulla. 
Now and then one finds nodules the size of a small j>ea in the struc- 
ture of the wall of a tulx? (salpingitis nodosa), these being found 
generally in the isthmus. On section they show a dense fil)ra- 
muscular Mructure containing glan<llike sjjaces, which sometimes 
represent the lumen of the tube. Tubes containing these nodes are 
apt to be impervnous. The condition is not to be confuscil with 
nmhdar tuberculosis of the tul>e. 

The ostium of the tutx* is commonly closed by peritonitic adhe- 
sions or exudate in cases of chronic purulent salpingitis, but otivn 
on separating the adhesions it will Ix^ found that the fimbriirai'e 
free and the ostium is patent. It is probable that these are the 
cases in wdiich, upon the subsidence of the inflammation and the 
absorption of the exudate in the jK^ritoneum, the ostia become 
pervious again. In many cases, especially tliose due to gonococcus 
infection, the fimbria' arc found adherent and there is true occlusion 
of the ostium. 

In the case of chronic salpingitis infection from the tube may 
be transmitted to the ovary ^ antl a tu!>o-ovarian cyst or tub^v 
ovarian abscess may result, or the process may be linuteil to the 
tube, salpingitis proper. 

Symptom*^ and Diagnoms, — The sym]>toms an* |>ains in flu* gmins, 
a sense of weight in the pelvis, exacerbations of h*ver, irregular- 
ity of menstruation, dysmenorrhea, and vaginal ilischarge. The 
I diagnosis is made by palpating enlarged tulx^s, by the presence 
of preceding and coinci<lent endometritis, and by symptoms of 
I>ain anrl fev<»r not accounted for by the enttometritis. 

Salpingitis due to the streptococcus is k^ss apt to affect both 
tubes than is the gonorrheal variety. 



330 DISEASES OF THE FALLOPIAN TUBES 

Gonorrheal Salpingitis. — As a rule it is a long time, months or 
years, before the gonococci of an endometritis reach the tubes, 
although they have been found in the tubes within two weeks 
after the initial infection; therefore the disease is generally de- 
scribed as being subacute or chronic from the start. 

The disease is usually bilateral and may be ushered in by a chill, 
fever, and local tenderness and pain. In the more chronic stages 
the amount of tenderness is variable and may be wanting, th(?re 
is generally no fever, and the patient may be in fair health 
except for anemia and debility; but during the menstrual 
periods there are dysmenorrhea, local tenderness, irregularities 
of menstruation, and increased vaginal discharge as troublesome 
symptoms. Acute attacks of inflammation are apt to occur in 
the history of chronic gonorrheal salpingitis and whenever a 
drop of pus escapes into the peritoneal cavity there is inflam- 
matory reaction. 

As previously stated, the ostia of the tubes are more apt to be 
closed by gonorrheal than by streptococcic inflammation, thus 
accounting for the sterility of prostitutes. 

Diagnosis. — ^Unless the gonococci can be found in the discharges 
from the uterus there is no way of distinguishing this form of 
salpingitis from any other. The probabilities may point in this 
direction from a history of gonococcus infection, from the occur- 
rence of gonorrheal joint affections, or from evidences of past 
inflammation in the vaginal or inguinal glands. 

Tuberculous Salpingitis. — The Fallopian tube is the most frequent 
site of genital tuberculosis in the female. Where careful routine 
microscopical investigations have been made of all the clinical 
material furnished by the operating-rooms of hospitals it has been 
found that from five to ten per cent of all the inflammatory aflfec- 
tions of the tulx^s are tuberculous. Without painstaking investiga- 
tions it is impossible often to distinguish tuberculous from simple 
salpingitis. 

The disease may be primary in the tubes (it is generally bilateral) 
or secondary to a lesion or lesions at a distance, as in the lungs, or 
in a contiguous organ, such as a tuberculous ulcer of the intestine. 
The tubercle bacillus may come to the tube from the va^a by 
way of the uterus, or from the blood current. The infection may 
be limited to the tubes, or both ut(Tus and tubes are involved. 



SALPINOITIS 



331 



It is possible, and not a xt^ry uncommon hapjiening^ for the gono- 
C0CCU9 to be aissociated with the tiibcvrcle tjacillas, 

Palhology. — TuU^reulmis of the tuljes appt^an^ m tliree forms, 
miliary^ caseom^ anil fibrous. The appearances of tlie tube vary 
according as the disease began in the nuicous membrane linnig 
its cavity or in the peritoneal coat. The tube may te atrophied 
or much enlarged and tortuous and a part or the entire tulxr may 
l:>e affected. Mieroseopically tuljerculous nodules are fouod. These 
consist of a central giant ceU Burrounded by epithelioid cells and 
an outer zone of sriiall round cells. Caseous foci arc common and 
the folds of the mucosa are thickened and adherent. The lumen 
of the tube may be closed by a hyperplastic process affecting the 
mucosa just as ir the swelUng which accompanies infections by 



FiQ. 1 36, ^Tuberculous Salpingitis. (Dudley.) 

other organisms. The disease generally is progressive, but may 
Ik* arrer^ted, the tufx* being rejiresent^d in such cases by a thin, 
irniX'r\Hous, fibrous cord. If the disease progi*esses one exj>ects to 
find tuberculosis of the pi^ritoneum. 
K Diaffnosis, — Tul^t^rculous salpingitis is seldom seen in an early 

m stege when the diagnoi^is can he only that of salphigitis, A 

■ tuberculous history or tuberculosis elsewhere in the body leads one 
I to suspect the etiological significance of a salpingitis and some- 

■ times in the later stages fluid in the ix'ritoneum calls attention io 
I tuberculosis. Pyrexia, recurring every evening and disappearing 



332 DISEASES OF THE FALLOPIAN TUBES 

every morning, loss of weight and strength, rapid pulse, sweating, 
particularly at night, are symptoms of tuberculosis. 

Actinomycotic salpingitis is secondary to actinomycosis elsewhere, 
besides being very rare. The tubes are convert^nl into abscesses 
in which the characteristic yellow or brownish-black, sago-like 
granules are readily recognized. Under the microscope the acti- 
nomyces is recognized in the characteristic granulation tissue. 

Echinococcus infection is extremely rare also, and is secondary to 
hydatid disease in the broad ligament or elsewhere in the pelvis. 
Sometimes, but not always, pelvic hydatids are secondary to 
hydatid disease of the liver or other abdominal organ. Cases 
have been reported of tub(^s enormously distended by hydatids. 
The diagnosis would rest on the discovery of the disease in some 
neighboring organ or the passage of cysts from the vagina, rectum, 
or bladder. 

Syphilitic salpingitis must be regarded as a very rare disease. 
It has been found in the new-bom and extremely rarely in the 
adult. The tubes contain miliary gummata m their walls, and the 
folds of the mucosa are adherent. In one case in an adult, gummata 
the size of hazelnuts were found. The diagnosis is made probable 
by finding evidences of syphilis in other situations in the body, 
by the history of syphilis, and by the presence of an enlarged tube. 



RETENTION TUMORS OF THE TUBE, OR SACTOSALPINX 

Pyosalpinx is a Fallopian tube distendcnl with pus. The tube 
varices in size and shape. With moderate distention it is club- 
shaped, having a numb(T of convolutions; with more distention it 
is retort-shaped with the stem of the retort at the uterine horn; 
here the convolutions are more or less eliminated. With extreme 
distention the tuln* becomes an oval sac. These large tubes arc* 
uncommon. The* largest ones I remembiT having met were in the 
case of a woman twenty-thn^e yeai*s old, upon whom Dr. Clement 
Cleveland operated with my assistance January 20, 1890. The 
patient had Ixvn married one year and had not been pregnant. 
She had v(Ty few symptoms. The right tulxi measured six inches 
in length, and three inches in diameter at its outer end, and one 
and three-fourths inches at its inner end. Three inches of the 



RETENTION TUMORS OF THE TUBE 



333 



isthmian end of tlir tiilx' wrrt' ntjt uidargril. Thi*s tulx* hatl t'om- 
paratively few mlhcisions alx)ut it. The left tulx> inesLsurcil four 
ineht^s in length, and ttnu'c inehei? in diaraeter, and the surrounding 
a<lhesionH were iiensc* Eaeh wfni ovoid in shape and showed no 
convolutions. 

Ab a rule a pus tuk^ is surrounded by adhesions, bcK^ause its 
peritoneal surfaee is eiiveloprd hi an inflanunatory niernbnine. 
The pus is sterile hi over half of all cas(*s. This fact is explainett by 
the dymg out of the microorganisms which have caused the inflam- 
mation and arc* always to be found in the aeute and subacute cases. 
The walls of a j-jyosalprnx are generally thick, 1 jut they may te thin. 



F 1 G . 1 37 . — Py osalpin jE . 



In the older eases tln^ epithelial lining of the tube has been replacetl 
by granulation tissue. Ru|>ture uito the peritoneal ca\ity is an 
aeciileiit which has wcurnnl, although not very commonly. Q W. 
Bonnoy {Sunjery, (hpiecokMjy, and Obs-tetrks^ Nov., VMJ, p. M2) 
■ collected forty-five case-s, including the cas*:»s from the literature 
an<l a case of his own. In most instances there was no as.sigiiable 
cause for tin* rupture. Whenever hifection has set up an absccMs 
of the ovary as well as a pyosali.nnx the condition is knov^Ti as a 
tuffO-ovarian ahscess. This has been described under Pelvic Abscess. 
(See Cliaiiter XII, inige 193.) 

The diagnosis of jiyos^ilpinx will Ix* considered with the diag- 
noisis of hydrosalpinx and liemato.s;xl]/mx, 

Hydro^pinx is an accumulation of serous fluid in the tube. It 



DISE^VHES OF THE FALLOPIAN TUBES 

presupposos complete closure of the ostium abdominale, but not 
necessarily the lumen of the isthmus of the tube, and is the result 
of a pref'xisting salpingitis^. In intemiitlmt hydrosalpinx there is i 
a temporary obstruction to the uterine outlet of the tube caused 
by kinks in the isthtim^, that is, a mechanical stenosis exists. In 
such cases there is a periodic discharge of watery fluid tlirough the 
utc^rus. The shapes of tulx\s, the seat of hydrosalpinx, are the same 
as those of pyosalpinx, but the walls arc thinner and on micro- 
scopic examination are seen to l>e practically normal, except in 
the case of follicular hydrosalpinx^ in which there are evidences 



/\htmal i 










Fig, 138. — Hydrosalpinx, Two-thirds Actual Size, ^Author's Caae). 



of endosalplngitis. Hydrosalpinx is seldom larger than a Bartlett 
jK*ar, although cases have lx*en reported the size of a child's head. 
Tlie ampulla of the tube is cUlated with fluid more often than the 
isthmus. If an ovarian cyst connects with a distended tube by 
an adventitious openmg not the ostium abdominale., the condition 
is known as a iubo-ovarian cys^t. These cysts are by no means 
vineommon, and can not be distinguished clinically from hydrosal- 
pinx, except m those rare cases of hydro salpinx in wliich the normal 
ovary can b? palpated by bimanual toii(Oi. 

oatosalpinz is a Fallopian tulx^ tlistended with fluid bloocL 
di«ge occurring into a hydrosalpinx forms a hematosalpinx, 
iw believed that a majority of cases of hematosalpinx are 



RETENTION TUMORS OF THE TUBE 



335 



the result of tubal pregnancy and incomplete abortion. (Sec 
Tubal Pregnancy.) Hematosalpinx presupposes clo.siue of the 
ends of the tubt* just as in the case of pyosalpinx and hydi'osalpinx. 
Hemorrhage into the tube may take place as a n:\sult of torsion of 
the tutx' and it occm^s as a complication of fibroids of th<* uterus. 
It i.s found also in cases of imperforate hymen with accumulation 
of menstrual blood in the uterus {hematometra). 

Hematosalpinx resembles hydrosalpiiLx as to size and shape^ 
but is of a dark reddish-browii color. The walls are tlnek, but 



-Ufk 



mus Oj 



:flube 



Fig, 139. — HetiiatostilpirLx^ Actual 8ize, Causc^l by Acute Torsioii of Right 
Tube. Twist o( Two Turns to tlie Eight at tiie Istlunya. (Author's Case). 

friable, and covered by adhesions. On microscopic examination 
it is seen that the mucosa is tlegenerated and destroyed, the museu- 
lar tissue is swollen and infiltrated, while the peritoneal coat shows 
thrombosed vessels and deposits of blood pignient. 



Diagnosis of Sactosalpinx 

The diagnosis of pro, hydro-, and hematosalpinx rest^ on the 
determination by palpation of a tumor of the shape of a dUat(d 
tube connected with, but not a part of the uterus. If the noimal 
ovary can be disiinguislird se|)arat</ from the tumor so much the 
bf*tter. In the cas*\s whei'e the tulx^ is not very large the charac- 
teristic sliai>e— ^lub-ahat>tHl, pyriforni, or retort-shaped — can be 



336 DISEASES OF THE FALLOPAN TUBES 

made out with clearm»ss. Also in these cases the isthmus of the 
tube comiecting the tumor with the uterine horn may be palpated. 
With the larger tubes no characteristic shape can be learned by 
palpation. If both tubes are enlarged it is a strong diagnostic 
ix)int in favor of retention tumors because these are generally 
bilateral. 

Pelvic peritonitis with adhesions is an almost universal accom- 
paniment of these tumors, therefore they are more or less fixed. 
There is no means of knowing previous to operation the contents 
of a dilated tube, whether pus, serum, or blood. Aspiration Js 
not justifiable because by puncturing the tumor its contents may 
contaminate the peritoneum, thus complicating needlessly an 
o[)eration for removal, which is indicated in all cases. 

The diagnosis of rupture of a retention tumor is the same as 
that of rupture of an ovarian tumor (see page 319). 

Torsion to the point of strangulation is evidenced by acute 
stal^bing abdominal pain, vomiting, and the signs of a tender 
tumor in the situation of the tube. Torsion without stran- 
gulation has been reported in only three cases. Storer in 1906 
(M. Storer, Boston Med. and Surg, Jour., March 15, 1906, page 
285) r(»ported a case of bilateral torsion and collected sixty-two 
cases of torsion of the tube in the literature since Bland-Sutton 
first called attention to the condition in 1890. 

DiFFEIlENTIAL DIAGNOSIS BETWEEN SALPINOmS AND APPENDICITIS 

Right-sided salpingitis is often mistaken for appendicitis. It 
should Ixi remcmbcTcd that the two affections may co-exist, 
and hi this case which was in the beginning the exciting cause and 
whi(rh is tluj chief factor at the present time, are shown by the clinical 
history of the onset of the attack. Acute salpingitis is usually 
f)recedo(l by endometritis, by a vaginal discharge, and by menstrual 
disturbanc(*s, oft(»n by dysmenorrhea. In the case of appendicitis 
th(T(» is a history of digestive disturbances, of irregularity of the 
bowels, or of previous attacks of pain in the right side. Rovsing 
has made us(^ of a method of reproducing the pain of appendicitis 
that is of value sometimes in the differential diagnosis. He strokes 
the (l(»sc(»n(ling colon from Mow upward, and the transverse colon 
from left to right, thus forcing gas back mto the cecum and appen- 



dix, distending these structures and reproilueing a pain siniilar to 
that from which the patient has FufferetU 

In salpingitis the pain is more steady, less intense, and radiates 
into tlie pelvis, while in ap|>endiciiis it is rolieky ajid mow grneraL 

Dr. Rotert T. Morris (Jour. Amer, Med, Asso,, Jarniary 25, 1908, 
Vol. L., page 278) 1ms dirc^cted attention to two points of tenderness, 
eallcMl Morris^ pom/.% which he eonsiders of great assistance in 
distinguishing t:/etween elu'onic saljiingitis and ehronie appen- 
dicitis. One point is situated one and a half inches from the 
umbilicus on a line (bawn from the umljilicus to one anterior 
sujxTior spinous proeesss of the ilium, and the otiier {>oint is in a 
siniilar situation on the opposite side. These [loints are approxi- 
mately over the hmibar l>Tnph glands wiiich receive the Ipnph ves- 
st^ls from the Fallopian tulx-s, ovaries, uterus, and hroatl ligaments, 
and also from tlie appendix. McBurney's {>oint is on this same 
line on the right side one and a half inches from the spinous process. 
The right Morris' point is tender on pres^sure in the ease of chronic 
apiML'ndicitis not involving the Fallopian tulx', sometimes even 
when McBuraey's point is not tender. In the ease of salpingitis 
either unilateral or bilateral l>oth Morris^ jjoints are tender. Several 
physicians have reported satisfactory results from the use of this 
means of diagnosis ami it may l>e regarded as an accessory to other 
methods of diagnosis in chroni<* cases. 



NEW GROWTHS 



Primary new growths of tlie Falltipian tubers are relatively rare. 
They originate in the nuieosii, or in the walls of the tube, and are 
benign or malignant. The Ix-nign growths are, polypus, papilloma, 
erabryoraa, njyoma and fibroma, and fibromyxoma. T!ie malig- 
nant groTi^'ths are carcinoma, sarcoma, and clKjrioei^itlu^ioma. 
Polypus of the mucosa is rare. It consists of simiile inilanmiatory 
thickening of the mucous membrane or a polypus similar to a 
uterinf^ lJoIy[>us originating from placental tissue left attached to 
the tubal wall by a tubal pregnancy. 

Papilloma is thought to be a result of an old salpingitis rather 
ft than a neoplasm propter. E. Hunlon (*'G>mecology and Alxlominal 
I Surgery/' Kelly and Noble, Vol. I, p. 174) has eolieeted fourteen 
I ^ 



338 DISEASES OF THE FALLOPIAN TUBES 

cases from the literature. According to this authority the disease 
consists of a cauliflower papillary mass which originates in the 
mucous lining of the tube and distends the lumen without invading 
the wall. "Small peritoneal papillomata may develop, but metas- 
tases do not occur. Like the ovarian papillomata the tubal 
growths often produce an ascites. If, however, the abdominal 
ostium is closed, there is no ascites and the fluid is either retained 
in the tube or is discharged through the uterus (hydrops tubae 
profluens)." Papilloma of the tube is generally unilateral. 

Embryoma. — ^There have been at least four authentic eases of 
dermoid tumor of the tube reported in the literature, occurring 
in patients between the ages of twenty-five and forty-eight. One 
of the cases was an oval tumor the size of a hen's egg, which on 
section showed a tumor mass free in the tubal canal and having 
only a superficial attachment to the mucosa. 

Myoma and fibroma, occurring as small nodules in the tubal walls, 
are not to be confused with the salpingitis nodosa of gonorrhea 
or with the nodules occurring in tuberculosis of the tubes. Bland- 
Sutton says (*' Surgical Diseases of the Ovaries and Fallopian 
Tubes," page 286): "I have satisfied myself that when there is a 
general myomatous enlargement of the uterus, the muscle tissue of 
the tubes also participates in the change, becoming thick and hard." 

A true fibromyomatous nodule similar in every respect to uterine 
fibromyomata and the size of a walnut has been described as 
occurring in the tube. Even larger tumors have been reported. 
They are extremely rare. 

Fibromyxoma. — One case of fibromyxoma of the tube has been 
n^ported in the literature, the tumor being about the size of a fist. 

Carcinoma. — Hurdon refers to seventy cases of primary car- 
cinoma of the tube in the literature. The disease usually affects 
one tube, though it may be bilateral. It occurs most often in 
women who are between forty and sixty years of age and chronic 
salpingitis is thought to stand in an etiologic relation to the disease. 
It originates in the epithelial covering of the mucosa and develops 
in the form of a papillary tumor. The diseased tube is converted 
into a large cylindrical pear-shaped tumor, which may reach the 
size of a child's head, but is usually about the size and shape of a 
retention tumor of the tube. The disease may advance by direct 
extension to the surrounding structures or by metastases. 



NEW GROWTHS 339 

Sarcoma. — ^Therc are only five eases of this disease in the lit- 
erature, two round-cell, one spindle-cell, and one myxosarcoma. 
The tumor arises in the connective tissue of the mucous membrane 
or tube wall and presents a papillary or polypoid character. 

Chorioepithelioma of the tube, as a sequence of tubal gestation, 
seems to be relatively as frequent as chorioepithelioma of the ute- 
rus following uterine pregnancy. Hurdon notes eleven cases that 
have been reported. In the place of the tube there is a large sac 
with thin, friable walls, which encloses a soft, spongy structure 
resembling placenta, and masses of bloody, fibrinous material. 
Histologically the findings are the same as in chorioepithelioma 
of the uterus. 

The diagnosis of neoplasms of the tube can be only a probability. 
F<)rtunat(»ly they an^ very rare. After diagnosing a tumor of the 
tulx5 by palpation, the possibility of its being a neoplasm should 
be borne in mind. 

Tul>al prt^gnancy will Ix^ considered in the next chapter under 
Extra-uterine Pregnancy. 



CHAPTER XIX 

THE DIAGNOSIS OF EXTRA-UTERINE PREGNANCY 

Tubal pregnancy, p. 341: Frequency, p. 341. Etiology, p. 341. Pa- 
thology, p. 343. Uterine decidua, p. 344. Fate of the fetus, p. 344. Dis- 
eases of the ovum, p. 345. 

Ovarian pregnancy, p. 345. 

Symptoms and signs of extra-uterine pregnancy, p. 346: Pelvic hemat- 
ocele, p. 347. Multiple, combined, and repeated tubal pregnancies, p. JJ48. 

Diagnosis, p. 348: Early extra-uterine pregnancy, p. 348. Late extra- 
uterine pregnancy, p. 350. 

Differential diagnosis, p. 351 : Early extra-uterine pr^nancy before 
rupture, |). 351 . Early extra-uterine jjregnancy after rupture, p. 352. Late 
extra-uterine pregnancy, p. 353. 

DEFINITIONS 

By extra-uterine pregnancy we understand the development 
of a f(»rtilized ovum at some point between the Graafian follicle 
in which it originates and the uterus. 

The fertilized ovum may develop on the ovary itself, ovarian 
preijnaticy, on the fimbria ovarica, one of the fringes at the ostium 
abdominale of the Fallopian tulx^ that extends from the ostium 
to the ovary, so called abdominal pregnancy, or in the tube, tubal 
pregnajirfj. 

It is possible, and cases have been rejX)rted, of a fertile ovum 
d(»veloping in a tubo-ovarian cyst, the fetal sac being made up 
partly of tubal and partly of ovarian tissue. Such cases are s|X)ken 
of as Ix'ing tubo-ovarian pregnancies. When a primary tubal 
(ampullar) pregnancy has grown in its development into the abdom- 
inal cavity it is called a tubo-abdominal pregnancy , and when, at 
the ()|)|)()site end of the tuln*, a |)r(»gnancy Ix^ginning in the uterine 
end of the isthmus (interstitial pn^gnancy) develops into the uterus 
it is ref(nT(Ml to as tubo-uterine prcipmncy. 

True alxlominal pregnancy do(»s not (»xist, the cases reported 
as such iK'Uig those in which the growth of the fertilized ovum 

340 



TUBAL PREGNANCY 



341 



Ix^gan on ovarian or tul>a! >1ructure and the sub?si'(|iR*nt develop' 
rueiit was in the alxioniinal cavity- 



TUBAL PREGNANCY 

A vast nmjority of cxtra-utcrinr prognancies are tubal, and of 
these the ampullar form is |»robably the most common, though 
8c^nie authoFH assert that the isthniial variety lias tlie |jreectlenee. 
Tlie ifitf*rs1itial vari<*ty is the rarest. ^ 

Frequency.— It would ap|M.*ar that (*xtra-uterirte prej^nancy is 
more frequent than formerly, but whether thii? is really so or si>ems 



.♦W "^110 



FlQ. 140» — Blarly Ampullar Extm-ut^rino PrPKnunry^ Tubal Abortion, 
N at u ra 1 Si zo . ( K elly , ) 

to he so because of t^etter diagnosis and thi^ more cotrunon practice 
of oijc'nmg the alxlouK'ii, is not plain. Iti bS7fi Parry was al)le 
to collect only 500 cases from the literatun*; to-day the literature 
teems with them. Ont* prominent gynecologist in this country 
has iTjKjrted recently having seen as nmny as 3tXJ cases of extra- 
uterine pregnancy, another 2(>i), and a thinl has operated on 154 
cases. Still another oj>emtor says that operations for extra-uterine 
(pregnancy form about four per cent of all his aI>dominal oper- 
aticjns, and in my own experience such operations have lx*en nearly 
five [jer cent of all my celiotomies. 
Etiology.— As to the causation of tubal pregnancy we are still 




Fig, 141.— Same Caae aa Iil^ i in rfi>- Mnl* ami di. i 
itiuvml from the Tube. (Kelly,) 

though in a t-crt^in proj>ortion of vtLHv^ ovon the most ean*fu|l 
histoiy of the patient and thorough microscopic examination 
of the speciiiK^n %vill fail to reveal a tangible cause for the condition/* 
Ajjy woiaan t luring the childlxiaring age may have extra-uterijTC 
pregnancy. It is more often ohservcil in women who have been 
pit!vioiisly sti^rile or whrn there has been a long interval sinee^ 
the last pregnancy. 




Pathology.— 11 api>ears that the ovum 
placL*nta is fomied in the tube exactly as in the uterus. The tube 
wall is invaded by the festal elements, its structures Ix'eome degeii- 
eratetl and in part eunverleii into fibrin so that they offer com- 
paratively httie resistance to tlie developing fetal cells. Shortly 
the latter are found just uniler the peritoneunu In a majority 
of ca'M^s early rupture of the IuIk' is flue to the erosion of a large 
blood-vessel with consequeet hemorrhage and a giving way of the 
thin p*?ritoneum. 

Tubal pregnancy may terminate by alwrtion mto the lumen 




Fro. 142. — Fehic Heiuatoeele. 



of the tube, the most freiiuent issue; by rupture into the j>eri toned 
cavity, bcjth of tlit'se taking place iluring tlm first ft'w weeks of 
pregnancy; or by tlevelopment even to term. Rupture is more 
common in pn^gnancy in the isthmus, and abortion in ampullar 
pregnancy. 

As far a8 the results go it makes little difference whetlier early 
niptuix* takes plai*e through tlie capsular membrane into the 
lumen of the tube or through the wall of the tub'. There is a 
hemorrhage in either ease. The ovum with its membranes is (1) 



344 EXTRA-LTERINE PREGNANCY 

separated completely from its bed and is expelled into the lumen 
of the tube and perhaj)s through the ostium, or (2) is expelled 
through the tubal wall directly into the peritoneal cavity or, (3) 
the separation is partial, the ovum remains, and the hemorrhage 
continues. The last, incomplete abortions, are the most frequent. 
WTien the ovum and its envelopes are extruded at once through 
the ostium abdominale the hemorrhage may cease; when, on the 
other hand, the separation of the o\Tjm from the tubal wall is 
only partial, the ovum may increase in size because of infiltration 
with blood, and a tubal viole is formed. Under such conditions the 
hemorrhage continues as long as the mole remains in the tube 
and the blood trickles from the ostium and forms a pelvic h(^ 
matocele instead of free hemorrhage into the peritoneal cavity as 
in the case of complete abortion or tubal rupture. 

Tubal rupture occurs more frequently in isthmial and interstitial 
pregnancy than in ampullar pregnancy. In interstitial pregnancy 
rupture may not occur until as late as the fourth month, whereas 
in isthmial pregnancy rupture generally occurs within the first 
f(»w weeks of pregnancy, not infrequently before the patient is 
conscious that she is pregnant. 

Rupture occurs near the placental site and is either into the 
pc^ritoneal cavity or Ix^ween the folds of the broad ligament. 

Uterine Decidua. — A decidua, very similar in structure to the 
decidua of uterine pregnancy, is fomied in the uterus coincident 
with the development of the ovum in the tube, and it is cast off 
soon after the death of the fetus either in small pieces, or, rarely, 
as a complete triangular cast of the uterine cavity. (Sec Fig. 143.) 
Hemorrhage from the uterus is apt to occur when the decidua comes 
away, but the membrane may be passed without the patient's 
knowledge?. If portions can be obtained for microscopic examina- 
tion, either from discharges or by curetting the uterus, they furnish 
a valuable diagnostic sign. 

Fate of the Fetus. — The extruded ovum is always killed and is 
absorbed by the peritoneum unless it is advanced beyond the 
third month. It is highly improbable, as thought formerly, that 
the placenta can be attached to other structures in the abdominal 
cavity, at this time. The facts go to show that attachment is 
primary either on the ovary or tulx* and that any other adhesions 
are due to the later stagers of the development of the fetus and 



OVARIAN PREGNANC\' 



345 



placenta. If the rupture is between {hv UMs of tlie broad ligarnerit, 
a mrv hapjiening, the ft^tus dies and a heiiiatoma of the broad 
ligament is formed. Exceptionally when the plaeenta is not 
injured pregnancy may continue in the broad ligament or the 
broad ligament sac may rup- 
ture into the peritoneal cavity 
and a secondary ahdominal preg- 
nanetj results. 

If the fetus has developed 
beyond the third month it may 
Ix* jnummijietf, consisting of an 
aljsorption of the* fluid |)ortion.s 
fio that there is nothing left but 
shriveled skin holding together 
tlie l>ones of the skeh^on, or, 
ran^ly, it may form a lithope- 
dion, a mummified fetus in 
which lime salts have been d<*- 
positinl Sometimes the dea^l 
fetus and its membranes sup- 
purate an/1 an aliscfss is formeil p,^^ H^.-rtc^rine DocM.m from a 
and very exceptionally this fetus Case of Extra-l t<jrine Pregnane^', 

bx-omes converte<l into arfi/)o- (^^eifeU) 

cere, a sort, of amnioniacal soap found o<Y*asionally in dead bodies. 

Diseases of the Ovum. — The occurrence of tulml molf^ ha*s been 
referre<i to already, (See page 344/) Hydalidiform jnole has Iw^en 
found in the tuiu' and differs in no respc*ct from hydatidiform 
mole occurring in the uterus. In ttiis situation it is followed by 
chorioepUhdionm just as in the uterus. 

In most cases of ailvanced tubal pregnancy there is a diminution 
in the amount of liquor amnii, but hydramnios has l>een ol>served. 
There are two cases on record of patients who had eclampsia 
during falsi' labor. 



OVARIAN PREGNATfCY 



J, Whitridge Williams has collected from the literature thirteen 
positive cases of ovarian pregnancy, in eleven of which the preg- 
nancy had not progressed lx\vond the fourth month. In addition 




1 



d46 



EXTRA^IITERINE PREGNANCY 



he classed as higlily probable or }>ri>bal)lt' ovarian iiregnaney, 
twenty-two other ca8(*«. In eleven of these thirty-five cases 
pregnancy had progressed to full term, so tliat the inference Is 
that the ovary can aceoinino<iate itself more readily than the 
tube to the growing fetus. Early rupture is the rule, however. 



Amnion. 



Parlially 
separated 
placenla. 



Ulerine 
cavity. - 



V^ 



Cervix. 



l' 



Fig. 144. — Int<?rstilial Pregnancy. (Bumm), 

in ovarian pregnancy, just as m tubal pregnancy. It is possible 
for the ovura to be destroyed early without rupture and ovanun 
henmtoma may result. The implantation of the ovum on, or in, 
the ovary does not diflfer from the emix'dding in the uterus except 
that a defkiite decidua is wanting. 



SYMPTOMS AND SIGNS OF EXTRA-UTERINE PREGNANCY 

There are no symptoms to early unrupturetl extra-uterine preg- 
nancy and its discovery is only a matter of chance. Slight pain 
in the ovarian region may be present. Amenorrhea may be a 
symptom, but cases are recorded of rupture l>(:^fore it was time 
for another menstrual periml, the t>atient having no idea she was 
pregnant. Suppression of menstruation Ls not as frequently a 



Ffiyraptoin with extra- as with intra-uterine pregnancy, perhaps 
due to the presence of the utiTine decidual and if ruptiiR- or 
abortion take^ plaee in tho tube there is hemorrhage from the 
uteriLs. Sometimes the patient think.s herself pregnant and there 
may be present signs in the breasts, bluish diseoloration of tlie 
anterior vaginal wall and the introitus, together with enlargement 
of the Fallopian tube on bimanual pal(>ation. 

It has lx*en my experience that the patient has skipped one 
menstrual period and has some sympton^s of pregnancy before the 
symptoms of rupture occur. These are sudden, severe, lancinating 
pain in the groin, bearing down, and rectal tenesmus^ followed 
at once by faintness and sighing respiration with colla|>se, pallor, 
distention of the abdomen, a fec»ble rapid pulse, and subnormal 
tempcratiu-e. Patit^nts se^ldom die of this first hemorrhage, but 
after a few hours there is another attack of pain, followed by greatcT 
eollaps*}, and if there is no surgical aid death may follow% 

No two cases are alike, one will bleed rapidly and another slow^ly. 
Further, the amount of collapse does not seem to be* in direct 
ratio to the amount of blocwl which has escaped into the peritoneal 
ea\'ity, for upon operation it is found sometimes that when the 
abdomen is full of lihMxl the symptoms have not teen severe. In 
other cas<\s most alarming sjrmptoms follow the extravasation of 
a small quantity of blood. 

Pelvic Hematocele. — If the blood has trickled out of the ostium 
of the tube^ as in tubal atK*rtion, or if for any reason the discharge 
of blood is intennittent, there will Ix; a sc^ries of attacks of pain, 
perhaps a week or two apart. In these cases a pelvic hematocele 
is generally formed. The bloo<l collecting in the pelvis is partly 
coagulated and is walled oflf by an organizeil membrane of perito- 
nitic exudate. iSuch a collection may be a isoUtury^ or a diffui<e 
^lenuUocelej the fonner term k*mg applied to a smaller collection 
of blomi in the neighlM)rlKMMi of the Fallopian tube. 

Local examination shows a lx>ggy mass, also softness of the 
cervix, and pain •on mo\ing it forward with the finger. Bluish 
discoloration <*f the vagina may be present. Colostrum in the 
breasts is an unreliable symptom* In some cases of early rupture 
there is a uterine discharge of a brc:)w^iish color w^hich may con- 
tinue for weeks. This Ls due to the disintegration of the dcMi'idua 
in the uterine cavity. 



1 



348 EXTRA-UTERINE PREGNANCY 

The pelvic hematocele is generally situated in the cul-de-sac 
of Douglas. If the uterus happens to be retroverted and the cul- 
de-sac obliterated the blood may Ixj effused in front of the uterus 
and in that case the hematocele will be found anteriorly. A fresh 
hematocele is flaccid and fluctuates; an old one is hard and may 
be of uneven density. 

If rupture does not result in death and there is no surgical 
interference pregnancy may continue and secondary abdominal 
pregnancy may follow. Then the symptoms will be those of preg- 
nancy, with more pain and more suffering from the fetal movements 
than in uterine pregnancy. False labor sets in at term with uterine 
contractions and pain. The fetal sac contains so few muscular 
fibres that it can not contract to any great extent. The false labor 
may last a few hours or a number of days and is followed by the 
death of the child. 

Multiple, combined, and repeated tubal pregnancies are reported 
in the literature. Twin tubal pregnancies occur occasionally, 
both embryos being in the same tube or one in each tube, and 
Sanger and Krusen, according to Whitridge Williams, have reported 
cases of triplet tubal pregnancy, all of the embryos being of the 
same age. Combined extra- and intra-uterine pregnancy is not 
very rare. Weil)el in 1905 had collected 119 cases from th(» lit- 
erature. This class includes only the combined pregnancies in 
which the embryos were of the same ag(*, and not the cases of 
uterine pregnan(*y occurring in the presence of the remains of an 
old extra-uterine pn^gnancy. 

There have lx?en many cases on record of repeated tubal preg- 
nancy in the same woman, and several cases of this have fallen 
under my observation. 

DIAGNOSIS OF EXTRA-UTERINE PREGNANCY 

Early Extra-utkkixk Pregnancy 

V 

The positive diagnosis of early tubal pregnancy before rupture 
has Ixren made and has been proved by opcTation. Such a diag- 
nosis is based on the symptoms and signs of (iarly pregnancy and 
the presence of a tender unilateral tumor of the tube and slight 
enlargement of the uterus, more c^spc^cially if the woman has been 



DIAGNOSIS 



340 



sterile, or a long interval has elapsed since the last pregnancy. A 
diagnosis uniler these conditions is onJy pr(jbal)Ie» however. Any 
patient presenting such a combination of f^ynif>toins and signs 
should Ik? kept under continued observations until the diagnosis 
is made phiin or an operation is performed. The death of the fetus, 
usually bt^tween the fourth and the ninth w(*ek of pn^gnancy, is 
signalized by the tlischarge of the uterine decidua and Ijy more or 
less hemorrhage from tlie uterus. At tliis time the diagnosis is 
apt to be uterine abortion. Always earefull;^ examine the ovaries 
and tulws in cases of aliortion and if possible get shreds of extrudeil 
tissue for microscopic examination. In exfoliative endometritis a 
cast of the uterine cavity may be throwTi off, and therefon.* tlie 
extrusion, in extra-uterine pregnancy, of the tleeidua in one piece, 
triangular in shape, is not i)roof jjositive of the existence of this 
disease, but may l>e classed as presumptive evidence. On the 
other hand, the cast-off dt'cidua may Ih.^ lost at an earl}^ date, 
perhaps without the jjatient^s knowhtlge. A tubal tumor of a 
size corresix>nding to the length of time the suppost*d pregnancy 
has existed, a slightly enlarged utei'us, a relaxed vagina w^ith 
l>luish discoloration, a vaginal <Jischarg(* of blcHMl and shreds of 
tissue, and pain caused by pullbig tlie cervix forward witli the 
finger in the vagina make the diagnosis of tulml pregnancy most 
{irobable. 

The spnfitoms of rupture have lx»t»n eonsiilcred under the 
heailing of symi»toms, page 347. They are characteristic. Sudden 
faintness and collapse, together with severe pain in the region of 
the pelvis in a woman who has gone over her period^ make a prot> 
able iliagnosis of rupture of an extra-uterine pregnancy. If tlie 
patient recovers quickly the prolmbilitics are in favur of its bring 
iuYtsl ab(jrtion. If there are recurrent attacks and a hematoc^ele 
can be made out — a boggy mass of indefinite outlin*^ — the diagmv 
sis of tubal abortion is untioubted. If the patient goes from bad to 
worse, and there are rigiiiity of the alxlomen, increasing alKlomi- 
nal pain, pallor, sighing respiration, subnormal iemiM^rature, and 
a threatly pulsr, tlie diagnosis is tubal mixture and tlie aUloinen 
shoukl Ijt; opi^netl at once. After the first attack of cotlai)se^ and 
pain, there is to be felt a mass in the pelvis. 




I 



DIFFERENTL^L DIAGNOSIS 



351 



pain than is usual in normal pregnancy. The sound Diay be paast^l 
into the uterus to determine that it is empty. 

At full term the diagnr^sis is matle by a history of false later 
followed by a gradual ilecrease in the size of the ab<lomen. The 
uterus is nearly nonnal in size and di*sp laced by a large tumor 
either for^^^ard or backward. The child can l>e palpated and, if 
alive, the fetal heart j^ounds can be heard. The diagnosi,^ at full 
tenn is ea.sy to make, whereas pre\ious to this time it i.s thfficult. 

The diagnosis of conibinefl intra- and extra-uterine pregnancy 
is seldom ma^lc* previous to labor or operation. Sometimes in the? 
case of twins when a child ha.s Ixx^n Ixim from the uterus and there 
is delayed birth of a second child, <\\aoiination leads to the fliagno^sis 
of extra-uterine fetatioTL Also, operation for ruptured extra- 
uterine pregnan(*y with alxlominal hemorrhage may show the co- 
existence of uterine i>regnaney. 



DIFFEREHTIAL DIAGNOSIS OF EXTRA-UTERIire PREGNANCY 



Early Extra-Uterine Pregnancy before Rupture.— Heix^ any enlarge- 
ment of tuLM* or ovary not greater in size tlrnn a goose egg may 
be mistaken fur an extra-uterine fetation. The pres<*nce of the 
symptoms and signs of early (>regnancy (see Chapter XXII, page 
418) and the fact that an extra-uterine sac is more apt to be tender, 
arc the only distinguishing features. 

Pregnancy in a retro verted uterus has been mistaken for extra- 
uterine i>regnancy. A thorough examination, if necessary with 
an anesthetic, ought to remove all doubt. The symi.jtoms which 
accompany retroviTsion of a gravid uterus should Ix* borne in 
mind, viz», difhculty io micturition, retention of urine, pains in 
the pelvis, and constipation. If the bladder is overdistended it 
may be palpatetl. Passage of the catheter establishes the diag- 
nosis. Uterine fibroids have been iiiistaken for a gravid tube, 
though this is rare. Fibroids are seldom single and the uterus 
is apt to be distorted by their growth. 

Early Extra-Uterine Pregnancy after Rupture. — vSymptonis and 
signs of early pn^gnanry with a paroxysm of severe alxlominal 
pain, collajise, distention and rigidity of the alxlomen, thrc^ady 
pulse and subnormal teni|>erature, besides m€*aning ruptured 




353 



EXTRA-UTERINE PREGNANCY 



extra-uterme pregnancy, may indicate rupture of an ovarian cyst, 
or torsion of the jx^UcIe of an ovarian cyst, ruptur(^ of a j>yosxLlpiiiin 
or even of an appendiceal abscess, or ruptin-e of a varicose vex, 
of tlie broarl ligament. Tin* treatment is the same in all of these 
conditions, iinmetliate opening of the alxlomen. 

If the rupture has been into the folds of the broad ligament 

tliere will Ix^ a mass of irregular 
^-5- -''*. outline at tlie side of the uterus, of 

^m doughy consistency. It is to be 

JB /, \ differentiattxl from a pelvic inflam- 

^^ '^^ \ ntatory mass by its lack of hard- 

ness, by the alistniee of the history 
k, I of infection^ and by the absi*nce o{ 

' the signs of infection in vagina and 

cervix. 

In the event of s>'mptoms of acute 
rupture in uon< litions sinmlathig 
extra-uterine pregnancy tlie history 
of the ease will throw light on the 
diagnosis. In the case of an ovarian 
tumor the history will show the pre- 
vious existence of a tumor, except 
in the case of a small one, and the 

T uterus is not enlarged; in the case 

I . of pyosalpinx there is a history of 

•X ' genital infection and the temjxTa- 

ture is apt to be elevated, also the 
symj)toms of hemorrhage,^ — weak 
heart, pallor, sigliing respiration, 
and syncope, — arc absent. In the 
case of rupture of an appendiceal 
abscess^ the same is true and in 
adilition there is a history of di- 
gestive disturbances, constijiation 
alternating with diarrhoea, and, usually, previous attacks of 
riglit-sided pain. In cases of chronic rupture, those* in which the 
symptoms are not severe and prolonged, uterine abortion is one 
of the conditions most apt to h^ mistaken for extra-uterine preg- 
nancy. If there is any doubt at all that the case is one of uterine 



Fio. 146, — Meclian Section fif 
the Uterus of a Case of Isthiniftl 
Tubal Pregnancy of altout Two 
Months, Showing the Uecirlual 
Morlificiition of the Endometrium, 
(Coyvelaire.) 





DIFFERENTIAL DIAGNOSIS 

abortion, ether should be given ami a thorough bimanual exanii- 
iiation made. The uterine hemorrhage in cases of extra-uterine 
pregnancy is generally of less amount than in cases of abortion 
and the clots are les?s frequently jiassed. The pain of rupture is 
a seven?, agonizhig sensation, one that can not be enduretl; in 
the beginning it is unilateral. The pain of almrtion is that of 
labor, Ix'ginning as an achhig, drawing pain in the lumbar region 
radiating toward the hypogastriLmi, 

The changes in the size and consistency of the uterus are more 
marked in uterine than in extra-uterine pregnancy. In the case 
of acute pyosalpinx or an exacerbation of a chronic j^yosalpinx 
there are no softening of the cervix and no |>aiii when the cervix 
is moved forw^ard as in the case of extra-uterine pregnancy. In 
the ease of niitture of varicose veins of the l>road ligament, a rare 
event, there is nothing to jioint tow^ard a diagnosis nnleas the 
patient has been luider observation previous to the rupture. 

According to Baumgarten and Poffer (Wiener kliniscbe Wwhenr- 
schriftj 19f>6, No. 12) acetonuria is present in extra-uterine preg- 
nancy. They examined the urme of one hundred patients and 
were able, by detecting acetonuria, to cUstinguish bc*tween extra- 
uterine pregnancy and other pelvic tumors. 

Late Extra-uterine Pregnancy. — If the walls of a pregnant uterus 
are abnormally thin, and the walls of the mother's abdomen are 
also thin, the fetus may tie so |>laiidy felt that a uterine may Ijc 
mistaken for an extra-uterine fetation. Careful bimanual pal- 
pation will determine that tlie fetus is in the uterus. So, also, a 
sacculated pregnant uterus may simulate extraruterine pn^gnancy, 
m well as ijregnancy in a bicorned uterus. In the latter case an 
other examination may serve to differentiate. 

A late extra-uterine pregnancy with an excess of hydramnios 
may simulate ovariati cyst. If the fetus can be outlined by jial- 
pation, or the fetal heart heard, the diagnosis is easy. 

The consideration of pregnancy in abnornuil uteri, such as 
bicorned antl rutlimentary, will be found in the chapter un preg- 
nancy, page 432, 



23 



C'HAITER XX 

THE DIAGNOSIS OF DISEASES OF THE VAGINA 

Anatomy, p. 354: Vaginal discharge, p. S3o. Age changes, 35G. 

Malformations of the vagina, p. 356 : Congenital malformations, p. 356. 
Acffuired stenosis and atresia of the vagina, p. 359. 

Inflammations, p. 361 : Acute vaginitis, p. 36^. Chronic vaginitis, p. 
363. Condylomatous vaginitis, p. 363. Emphysematous vaginitis, p. 364. 
Mycotic vaginitis, p. 364. Ulcerative vaginitis, p. 3^. Senile vaginitis, p. 
365. Tuberculous vaginitis, p. 365. Syphilitic vaginitis, p. 365. 

Displacements of the vagina, p. 366: Cystocele, p. 366. Rectocele, p. 
369. Hernia or enterocele, p. 371. 

Injuries of the vagina, p. 371 : Lacerations of the perineum and pelvic 
floor, p. 371. Other injuries, p. 372. 

Foreign bodies in the vagina, p. 377. Gas in the vagina, p. 378. 

Vaginismus, p. 378. 

New growths of the vagina, p. 379. 

Fistuhe of the vagina, p. 384. 

ANATOMY 

The vagina is a slit in the [)elvic floor extending from the hymen 
to the cervix uteri and lying between the bladder in front and 
the rectum behind. It is nearly parallel to the plane of the brim 
of the true pelvis, and, with the patient in the upright posture, 
makes an angle with the horizon of about 6(F. When seen in a 
median longitudinal section the slit of the vagina shows an S curve, 
the height of the first anterior protuberance of the S being at the 
summit of the perineal body. (See Figs. 6, p. 44 and 85, p. 219). 
In horizontal section in its middle course it is seen as an H-shaped 
op(»ning. (S(»e Fig. 151, p. 374.) Like the cavity of the uterus it is 
funnel-shap(»d, l)eing larger alx)ve and smaller below, and it lias two 
walls, an anterior and a posterior, which are in apposition uidess 
the vagina is distended. 

The anterior wall ext(*n(ls from the hymen below, to the cervix 
abov(^ th(i anterior fornix being th(» space formed between the intra- 
vaginal portion of the cervix and the upixT portion of the anterior 

354 



ANATOMY 



335 



wall. The length of the anterior wall i^ from two to two mid a half 
inches (5 to 6 centimeters). In its lower ix»rtion it is clot^*ly 
united with the urethra, but higher up is surrouiidetl by loose 
areolar ti^ssue. 

The posterior wall extends from the hymen to the cervix uteri. 
It is three inches (7.5 eentimeteiT^) long or nt*arly an inch longer 
than the anterior wall. The space between the vaginal i>ortion 
of the cervix and the upper part of the pOi>terior wall is calletl 
the posterior fornix. It is deepcT than the antt»rior fornix. 

The mucous membrane of the Viigina is arrang<*(^l in transverse 
folds or rugie. In the lower i>art. of the centre of each wall is a 
shigle or double longitudinal Uiickenlng about st^ven-eighths inch 
long, known as the column of the vmjina. The anterior column is 
tlie larger. 

The vagina is ma<le up of three coats, the mucous membrane. 
the muscular coat, and the erectile tissue lying between the two. 
The arrangement of the mucous membrane in fohls has lx*eu 
iieserilR^l. The epithelium eovt'ring the surface of the nmcous mem- 
brane is of the scjuamous variety. There are no functioning glaruls, 
although the presence of glantl tissue in the mucous membrane 
has Ix'cn proveil by von Heiff and It. ih^ver. Tlie muscular coat 
consists of two layei-s, an external longituilinal, tlie stronger, and 
an internal, weaker, circular layer. The loose connt»etive tissue 
uniting the mucous meoibrane witli the muscular coat contains a 
plexus of veins wliich are arranged similarly to the veins in other 
ert*ctile tissues. Because of its opening near the anus and the 
urethra, and its being invaded by the jjenis, the vagina is esiM'cially 
suljject to inflection from outside. Bacteria may Ur l>rought to it 
from tlie uterus and trauma may comt^ from childlxaring. 

Vaginal Discharge.^ — Although under normal conditions po.sses- 
sing no functioning glands and therefore no stTreticjn proper, the 
surface of tbe vagina is covered by east off e|»tthelial cells ami 
also bacteria with moisture having an acid reaction. This has a 
wliite creamy color anil is not enough in amount to attract the 
woman's attention. The aciflity of the fluid may te due to the 
lactic acid bacterium of Doderlein, though authorities are not 
agjeeil on this [joint. Be tliat as it may, pathogenic bacteria, unless 
es|x^ially virultmt* do not live long in a healtliy vagina, not finding 
a good eultuj'e medium or Ixiug killed by the microorganisms 



M 



356 DISEASES OF THE VAGINA 

already there. Under pathological conditions an excess of alkaline 
secretion from a cervical catarrh may neutralize the acidity of the 
vagina and render it alkaline, thus furnishing an opportunity for 
the growth of disease-producing germs. 

Age Changes. — In the child the vagina is narrow and there are 
many rugae. Its walls are in close apposition. In the adult 
nulliparous married woman the vagina is more capacious, th(» 
widening being more in the upper than in the lower portion. 
After childbearing the vagina loses some of its folds, is larger, and 
may show alterations in shape because of its attachments being 
stripped from the cervix, or from laceration of the perineum. 

With the onset of the menoi)ause atrophic changes begin. The 
mucous membrane loses its ruga) and becomes smooth, and the 
vagina becomes contracted. In its upper portion the fomices arc 
obliterated because of atrophy of the cervix and shrinking of the 
vaginal walls. 

MALFORMATIONS OF THE VAGINA 

Malformations of the vagina are congenital or acquired. As the 
vagina as well as the uterus is derived from the coalescence of 
Miiller's ducts it partakes of the congenital malformations of the 
uterus. 

Congenital Malformations. — ^These are: absence of the vagina, 
atresia of the vagina, septate vagina, double vagina, and per- 
sistence of a Miiller^s duct, also the persistence of Gartner's duct. 

Absence of Oie Vagina. — ^This is not a very uncommon malfor- 
mation, instances of it appearing constantly in the periodical 
literature. It is associated with a greater or less degree of lack 
of d(*velopment of the uterus, the uterus being represented gen- 
erally by a small knob of tissue. The ovaries and tubes may or 
may not be prest^nt. If the ovaries are present the patient, other- 
wise perfectly formed as regards figure, external genitals, breasts, 
and hair, suffcTs from painful menstrual moUmina, and an oper- 
ation for the removal of the ovaries may be necessary. The anomaly 
occurs without assignable^ cause in well-nourished women in other 
respects fully developed. 

The diagnosis is established by noting the absence of the introitus 
vagina) and by the bimanual recto-abdominal touch practised 



MALFORMATIONS OF TIIC VAHINA 



357 



with the 



patient uiuler tlit- influence of an anesthelic. Something 
is learned also by palpation through tlie reetuni with a sound 
j)laced in the urethra and bladder. As a rule no vestige of the 
vagina can h(y found in the.se eases. The entire absence of the 
ovaries can not Ix* detennined surely without au abdominal section, 
but failure to find them in a case w^here all the conditions for 
examination are favorable, i.e., lax and thin alMlominal walls, 
together with the absence of menstrual molimitui, makes the 
diagnosis reasonably certain* 

Atresia of the Vagina {Congenital), — Vaginal atresia is due to 
the fact that the Miiller*s duets fail to coalesce properly throughout 
their entire course, and the lower end of the vagina may fail to 
reach the hymen. As a rule there is some portion of the unocclude*J 
vagina just under the cervix. In cases of congenital atresia of the 
vagina the vagina has been found dilatal with secretion so that it 
bulgnl Ix'yond the vulva, and lias Ix^^n known to cause rett^ntion of 
urine in the new-bom because of pressure on tlie lu-ethra. 

Occlusion of the vagina is to be differentiated from imperforate 
hymen, the latter, Ix'ing developed from the margins of the urogeni- 
tal sinus, is not a complete obstructive membrane. It is likely 
that when the hymen is closeii the closure is the result of ailhesive 
inflammation. The hjonen can generally be recognized as a 
separate structm'e bc*low the introitus vaginie. 

■ Any defect of the vagina that causes retention of thi* uterine 

■ secretions should Ix^ diagnoseil at birtli or soon after. 

^^^ In ^he case of doubk' uterus and vagina one vaguia may apjK^ar 
^^^ a blind sac rmuiing beside the well-formed vagina. It is thought 

■ now that most cases of atresia of the vagina owe their origin to 
I inflammatory proceas€\^, pcThaps diu-ing intra-uterine life, although 
I there are cases, mahily those associated with uterine abnormalities^ 
I that are due to failure of <levelopment pure and simple. 

I The (Hagnoeis Ls generally made by chance or by the occurrence 

■ of hematocolpos or liematometra due to retaintnl secretions in 
the vagina or uterus, 

■ Septate vagina and dmihle vagina occur when the septum between 
the Miillerian duct^ is partially or not at all absorbed. The partial 
form is more oftf*n obserA^ed. alth<:mgli all forms are rare. The 
septum may be placed diagonally s*) that it has the appearance 

I of a transverse septum, thus partially occluding one side of the 




wall of a w<4lHjcvf loped vagina and is connected alcove with a 
nidinif^ntary 8up<vriuii«crar)^ uterus while having no opening 
Wow, it may become dilated by retahied secretions and appear 
as a cyst. Freund antl otht^r^ have reiKJiled sneh eases. 



k 




MALFORMATIONS OF TIIE VAGINA 



359 



I 



Several cases of tlouble vagina have IxTn report tH I, ii<>tal)ly t>ue 
of double vagina aiitl ilouble uterus ri*ix)rtecl by II. A. Kelly 
("Operative Gynecology," 2nd edition, page 210,) (See Fig.147.) 

Gfirlner^s dud^ which in the emliryo extfiids as a small canal 
tlLrough the sidi* of the uterus or the l>road tigaitient^ tiie rervix, 
anil the lateral or anterior wall of the vagina nearly to the introitus 
vaginie, may persist in the wall of the adult vagina. This may, 
rarely^ give rise to cysts or even to an abscc'ss. 

Rt^tention of eeei-etions due to atn;%sia of the vagina, heinato 
coli>os, will be considered under actjuired stenosis and atresia in 
the section on inllannnations. 

The diagnosis of malformations is made by insjXH^tion and by 
<ligital examination. A small s|>cculum is necessary and sometimes 
a K(*lly cystoscope serves well for a view of an undeveloped 
va^ria. Bimanual reetoalxlotninal touch will deterniiuc the 
condition of the uterus and ovaries. 

Acquired Stenosis and Atresia of the Vagina. — Stenosis of the 
vagina is a constriction or narrowing of the canal, %vhile atresia is a 
complete closure or obliteration of it, 

J. Veit (**nandbych der Gynakolo^e," Bd. Ill, l9tlS) thinks 
that most of the forms of vaginal atresia that cause retention of 
secretions a»s seen in the adult (hematocolpos) are to be classed 
as acquircil, and assigns atlhesive inflammation in the first ytvii's 
of life as a cause. This inflammation is not as a rule severe mu\ 
has no symptoms often. We knfjw of tlu* frequency of gonorrheal 
\iilvo-vaginitis in little girls, and also that inflanmiatory affections 
of the vagina are found hi septicemia^ scarlet fever, ami diphtheria. 
Also, bacteria fincl ready entrance to the vagina in typhoid fever, 
dysentery, ami similar aflfections. Taken in connection with the 
frer|uency with which traces of infiamniatory action — for exairi|>lt% 
mlhesions of the prepuce to the clitoris — are found in adults ufMin 
cart'ful search, there s<*ems to be ample ground for the th<H)ry that 
this sort^ of atresia originat(»s in adhesive inflammation. 

In atlults the cause r>f cicatricial stenosis is intianmiatory action 
involving the submucous antl nmscular layers, due to injuries 
following childbirth, to caustic apiilications to the vagina, to 
improj^jti'ly |>erformeil operations on the vagina, to foirign bodies 
left in the vagina, such as neglected pessaries, and to vaginitis 
phlegmonosa disscccans. As a result there are found in the vagina 




360 DISEASES OF THE VAGINA 

cresccntic folds, ring-like narrowings, transverse septa with minute 
openings, all being forms of stenosis, or there is a general shutting 
up of the entire canal, atresia. This atresia may be caused by a 
thin membrane, by a broad cicatrix several centimeters thick, 
or by the entire destruction of the vagina. 

Atresia or stenosis results in difficulty in coitus and in labor. 
In the congenital form of atresia of the genital organs there is 
apt to be diminished desire for sexual intercourse, especially if 
the ovaries are undevelopd. Another result of atresia is hemato- 
colpoSy or accumulation of menstrual blood and uterine secretions 
in the vagina. These cases are generally first seen in girls who 
have passed the age of puberty without the appearance of the 
menstrual flow. They may experience pain in the abdomen. 
Examination shows a tumor behind the pubes that increases in 
size at each menstrual period and diminishes in the interval. 
On inspection of the vulva there is to be noted a bulging outward 
in the region of the introitus vaginae of an elastic tumor. The 
hymen is to be distinguished as a separate membrane. If the 
septum of the vagina is thin the dark color of the retained blood 
may manifest itself through the membrane. The bimanual recto- 
abdominal touch determines the presence of a fluctuating tumor 
in the situation of the vagina. 

If the accumulation of blood and uterine secretions has dilated 
the uterus, liematoynetra, it may be possible, with the aid of an 
anesthetic, to palpate the enlarged uterus. Dilatation of the 
Fallopian tubes from the same cause, hematosalpinx, sometimes 
results. In the latter event there may be an escape of fluid through 
the ostium abdominale of the tube into the peritoneal cavity with 
resulting peritonitis and symptoms of a severe grade. The danger 
of causing such extrusion of fluid should be borne in mind in making 
the bimanual touch and the amoimt of force used should be carefully 
limited. (Sch) Chapter XXI, p. 398). 

Diagnosis, — The diagnosis of stenosis and atresia of the vagina 
offers few difficulties. The examining finger detects folds and 
ridges and partial narrowings, also double vagina, if present. A 
small speculum is generally indicated, for with it the physician 
gets a better view of an abnormally narrowed vagina. An open 
canal with an elastic tumor by its side makes probable a dilated 
rudimentary vagina. Cyst of the vagina must be excluded, how- 



INFLAMMATIONS OF THE VAGINA 



361 



ever, and this can \ye clone by determining the ooriDal state of 
the uterus, tubes, and ovaries, as rudimentary vagina is seldom 
found with the other uterine organs perfectly normal. In all 
cases it is important to investigate the uterus and tuljes. 

Differential Diagnoms^-^Aciimwil stenosis and atresia must be 
different iatetl from the congenital malformations, from vuhatis 
with atresia, and from vaginismus. The congenital malforma- 
tions are of relatively rare occurrence and are associated with 
other defects of development in uterus, tubes, or ovaries, their 
salient characteristics having been referred to. In adhesive vnil- 
vitis there are apt to l>e traces of inflamniatory action (adhesions) 
about the clitoris and n>Tnpha% as well ns at the introitus vagina. 
There may be a history of gonorrhea, in this case look for cicatri- 
zation or redness in the neightorhood of the \iilvO'Vaginal glands; 
or there may Ixj a history of diabetes. Vaginismus is characterize^i 
by painful and spasmodic contractions of the muscles of the pelvic 
floor, especially those about the lower vagina. In cases of doubt 
the administration of an anesthetic will relieve all spasm. 



IFFLAMMATIONS OF THE VAGINA 

{Vaginilis nr Cdpilis) 

Infection of the vagina depends on the number and vitahty 

of the pathogenic bacteria that have found their way into it; also 
on the state of health of the epithelium of the mucosa of the vagina. 
Any direct injury of the epithelium, or change in its character due 
to a uterine catarrh favors the development of infective organisms, 
and their entrance into the tissues. Just what Imcteria are present 
as causative agents in any given case it is not always easy to 
determine; those that are most often found are the streptococcus, 
the staphylocfjceus, the coUm haeilliis, the tubercle bacillus, the 
gonococcus, and a gas-producing bacillus. 

Vaipnitis is relatively more common in children than in atlults, 
\ probably because of the softer epithelium in childhood. In children 
\idvo- vaginitis of gonorrheal origin is not uncommon, and vagi- 
nitis is a fre<iuent concomitant of the acute infectious diseases. 
In adults vaginitis is a rare disease* 
Etiology* — The following may be mentioned as predisposing 



362 DISEASES OF THE VAGINA 

and exciting causes of vaginitis: Retained discharges from an 
insufficient opening in the hymen; irritation from excessive 
venery or masturbation ; congestion from pregnancy or abdominal 
tumor, or organic disease of the heart, liver, or kichieys; gaping 
of the vulvo- vaginal orifice; douches of irritating substances, 
such as strong corrosive sublimate; foreign bodies, such as pes- 
saries and tampons; oxyuris vermicularis; injuries received at 
labor and abortion, and recto- and vesico- vaginal fistula). 

ACITTE VAGixms 

Pathology. — In the mild cases it is characterized by a reddened, 
swollen, granular mucosa which is bathed in an abundant thin 
purulent discharge. The entire vagina is usually involvc^l. In 
the severe cases, swelling and hyfxiremia increase and excoriations 
and even necrosis may occur. In puerperal conditions and in the 
acute infectious diseases the mucosa may be covered with a whitish- 
gray or greenish deposit or by a false membrane made up of the 
necrosed upper portion of the mucosa — pseiida-diphtheritic vaginitis. 
Cases of true diphtheritic mflammatiiyriy due to the Klebs-Locffler 
bacillus, have Ix^en described, though they are rare. 

In certain extremely severe cases the inflammatory process 
extends to the tissues about the vagina and there is a paravaginitis. 
This is the case in an erys^i pehitous vaginitis similar to the erj'sipelas 
of the skin, a rare disease*, and in paravaginitis pldegmonosa dis- 
siccanSy which sometimes accompanies typhoid fever. In the 
phlegmonous variety the whok* or the greater part of the tube of 
the vagina is cast off as a slough with subseciuent stenosis. 

Symptoms. — Burning pain refernnl to the vulva, a profuse 
leucorrheal discharge^ gen(*rally purulent in character and irritating 
to th(^ vulva, smarting on urination if the vulva is involved and 
also if urethritis is pn^senit, a.s in the gonorrheal form, a sense of 
fulln(*ss in thc^ pelvis, and backache, are the usual symptoms. 
Vulvitis go(\^ with vaginitis in many cases, especially in children. 
The constitutional symptoms are not marked, the temperature 
seldom going above 101° F., except in the streptococcic, diphthe- 
ritic, and paravaginitic forms. 

Diagnosis. — The pati(^nt is plac(Ml in the Sims position and the 
labia are separated. The charactcT and amount of discharge are 



INFLAMMATIONS OF THE VAGINA 



3a3 



notrd and a fmgvr |jla(*rd in thv vagina finds that it is hoi. In 
the gonorrheal variety, whieh 18 relatively rare aiitl is sc*eonilary to 
infeetioD of Bartholin's glands, the urethra, and cervieal canal, 
the diseharis^e is generally of a greenish-yelk^w color, Tlie smallest 
Sims speeuhun that will s«Tve is used because the vagina is very 
sensitive. The mucous menil)ra]ie shows sr^rne of the many char- 
aettTisties descril^ed under the iiathology of acute vaginitis. If 
the vaginal disciiarge originates from the uterus or an al>seess 
diseliargirig into the vagina instead of from the vagina itself, the 
siK-eulum examination will settle tliis i>oint. 



Chronic VAcmiTis 

Patiiology.— Chronie vaginitis may succeed aeutn vaginitis, or, 
more often, may iye of a chronic type from the beginning. It is 
apt to result from the irritation from |jessaries or tamtKms^ *.)r 
other foreign lx)dies. In the gonorrheal form it is usually secondary 
to gont^rrheal infection of the uterus, Bartholin's glamls, or the 
canal of the eervix uteri. 

Tlie disease is generally confined to certain [Kirtions of the 
vagina rather than to the* entire surface, as it is in the aeute fornu 
Tlie affected portions are redd(*ne<l^ often mottled with slight 
c»(*ehyinos<*s, or tliey are l>ro wn in color from old dt^iMisits of t)lood 
pigment. Tlie surface is granular, or glazni and smooth anil frt*e 
from nigir. Microscopically it is se^^n that the surface e[>it helium is 
somewlmt thituier than normal, whereas the submucous tissue is 
tliick, dense, and infiltrated with small round cells; sometimes 
blood pigment shows in deposits in places. In granular vaginitis 
the granulations on the surface are crescent-shapiHl, small in size, 
and pretty generally scatteriMl over the surface of tlie vagina. 
Certain special varieties of chronic endometritis are observed. 

Gonorrheal vafjinitis should Im* mentioned as a variety, although 
it has few^ eharactc^ristics that <hstinguish it fn*ni sim[jle vaginitis. 
It is generally secondary to gonococcus infwtion els4*where and 
the dist^-harge is apt to be of a greenish color, 

Cmidylmnatous Va/finilu. — Condylomata similar to thase found 
about the \ailva, but set not so close together, are to Ix" found 
sometimes m vaginjr that have U'vn subject to long-continuiHl 
irritations, as from gonorrheal endocervicitis. The condylomata 



364 DISEASES OF THE VAGINA 

may be scattered over a large or a small area in the vagina. They 
show under the microscope hyperplasia of the papillae accompanied 
by secondary epithelial proliferation. 

Emphysematous Vaginitis. — ^This variety occm^ most often 
dming pregnancy and occasionally dm-ing the puerperium, and 
is characterized by the presence in the vaginal walls of small cysts, 
generally not much larger than a pea, and containing gas. They 
may appear to be bluish in color due to the thinness of their walls. 
They are due to a gas-producing bacillus the exact nature of which 
has not been determined, and are developed in the connective- 
tissue spaces. Sometimes the cysts are as large as a filbert. On 
pressure with the finger the cyst disappears, and on opening it 
with a knife gas escapes. 

Mycotic Vaginitis, — ^This is a form of vaginitis in which there 
is a growth of a fungus in the vagina, the Oidium albicans. The 
walls of the vagina are covered with large numbers of grayish- 
brown, slightly elevated masses which are easily detachable. 
Beneath them the mucosa is swollen and eroded. Under the 
microscope the masses are seen to be made up of epithelial cells 
and the spores and mycelium of Oidium albicans. It has been 
thought that the dark color is due to blood-coloring matter. 

Ulcerative Vaginitis. — ^Ulcerative vaginitis is a term used to 
distinguish the form of the disease in which the mucosa has been 
destroyed by ulceration, as in the case of an ill-fitting pessary. 
Following the true form of ulceration in which the submucous tissue 
is involved a cicatrix results. 

An interesting case of ulcerative vaginitis in a case of bacillary 
dysentery has been reported by M. M. Canavan {Boston Med. and 
Surg. Jour., Nov. 11, 1909, page 705). In this case a woman fifty- 
one years old, an inmate of the Danvers State Hospital for the 
Insane for four years, was affected by bacillary dysentery during an 
epidemic of the disease in 1908. She died, just after a vaguial 
hemorrhage, on the fourteenth day of her illness. At the autopsy 
the following condition was found, to explain the hemorrhage and 
a bloody vaginal discharge* which had fx)(^n noted during the last 
six days of her illneas. The surface of the vagina was dull brown- 
ish-gray in color and was covered with a tenacious pigmented exu- 
date and there were clusters of deep-notched winding ulcers at the 
fomices of the vagina. 



INFLAMMATIONS OF THE VAGINA 



365 



Senile Vaginitis. — In senile vaginitis, a form of vaginitis peculiar 
to women who have passed the menopause, the mucous membraiK? 
is atrophic and thorefore jjoorly nourishes L The irritation of the 
vjigina from a uterine dij^charge is apt to proceeii to ihv stage of 
ulceration, generally many tsmall scattered ulcers Ijcing present. 
These enlarge, coalesce, cause hemorrhage by the erosion of small 
vessels, and form scar tissue. There njay be adhesions between 
the walk of the vagina. The disease is a commun one in women 
over sixty years of age. 

Tubercuhns Vaffinilis, — This variety is practically always second- 
ary to tulx*rculosis elsewhere, although a problematical case of 
primary tuberculosis of the vagina has been reported by Carl 
Friedlander and Olshausen. The disease, not a common one, 
occurs in tlu* form of one or more ulcerations^ generally situated 
in the neighborhood of tlie cer\ix. The ulcei*s are flat, circum- 
scribed, with infiltrated hyperemic margins, the Ijasc covered 
with yellowish-gray material or studderl with tulxTcles, I list* h 
logically the tlour of the ulcer consists of granular, caseous material, 
btmeath which the tissue is infiltraieil witli typical miliary tulxT- 
cles or diffuse tuberculous tissue. TIic tUagnosis is made by the 
microsco|x\ 

Si/philitic vaginitis needs only to be mentioned. Chancres, 
ulcers, or gununata may be found in the vagina. They are rare 
and are fliagnosi^Ll by the chaiiicteristic lesions of the disease in 
otlier parts of the \yody, by thi^ historj^ of syphilis, and by the de- 
tection of the spirocliaeta pallida in the discharge. 

Symptoms.— The symptoms of chronic vaginitis are vagina! 
discharge, generally purulent in character, a sensation of fuUness 
in the pelvis, perhaps itching of the vulva with smarting on urina- 
tion if the \^lva also is affected The general health may suffer 
I as a result of the irritation and consequent loss of sleep, but there 
* are no characteristic constitutional symptoms. Leucorrhea may be* 
' tlie only symptom. 

Diagnosis*— The patient is in the 8ims position. A Sims specu- 
lum is employed. It is noted tliat the vagina is not sensitive as 
in the acute stage and does not feel fiot to the examining finger. 
The mucous membrane is thickened and is of a dark reil or bluish 
color; in places it is smooth and in others it is roughened and the 
discbarge is thinner and less purulent than in the acute stage. 



A 



366 DISEASES OF THE VAGINA 

It is to be remembered that the vagina may be simply a canal 
which conducts purulent or other fluids from the uterus or the 
surrounding organs to the vulva; therefore be sure that the 
inflammatory process is primary in the vagina. In the case of 
gonococcus infection, as pointed out already, the process is second- 
ary to infection in the urethra, Bartholin's glands, and the cervical 
canal; conseciuently those situations should receive attention. 

The special varieties of vaginitis just enumerated should be 
borne in mind and their characteristics recognized. Cultures 
and smears are made from the discharges and pieces of tissue 
removed for microscopic examination in all doubtful cases. 



DISPLACEMENTS OF THE VAGINA 

In this section we shall consider cystocele, rectocele, and the 
rare condition known as true heniia of the vagina. 

Cystocele 

Cystocele is a prolapse downward of the anterior wall of the 
vagina together with the base of the bladder. It would appear 
that in some cases the muscular wall of the vagina has given way 
and the bladder wall in the cystocele is covered only by vaginal 
mucosa. If the urethra alone is dislocated downward the con- 
dition is called urethrocele. In this case the urethra may be detected 
as a thickened ridge, and passage of the sound together with 
palpation shows the situation of the urethra. 

Etiology and Frequency. — The chief cause of cystocele is child- 
bearing, the anterior movable segment of the pelvic floor, that 
portion lying betwcH>n the arch of the pubes and the uterus (see 
Chapter XIII, Etiology of Prolapse, page 223) being dislocated 
and stretched. Injuries of the perineum, actual tears of the 
anterior vaginal wall, and subinvolution of the vagina are con- 
tributory causes. Ru[)ture of the perineum and consequent lack 
of support to the anterior wall of the vagina is an important 
factor in the causation. Cystoc(*le is most often met with in 
working women who have less careful obst(^tric supervision than 
the women of the upper classics, and get on their feet before involu- 



DISPLACEMENTS OF THE VAGINA 



mi 



tioii of the utoru«, vagina, and perineum have Ix^n conipletinL 
As injuries of the perineum and jx^lvic floor are ilie ehief cause 
of siibinvohition it behooves the physician to diagnose and repair 
theise injuries promptly and tluus [*revent the oeeurrence of cysto- 
cele, which may not develop for 



'/i 



monthly or years after the re- 
ceipt of the injuries. 

Symptoms. — The symptoms 
depc^nd on the extent of tht^ 
|>rolapse. They are, a sensa 
tion of fuilnetss in the orifice of 
the vagina, and the feeling that 
soinetliing projects in that sit- 
uation on straining, the bulg- 
ing cystocele being mistaken 
for uterine prolapse; also drag- 
ghig and weight in the pelvis, 
in the ca^e of large eystocele 
and proIapse% and inability to 
empty tlie bladder easily. If 
the urethra is dislocated 
(urethi'oeele) there is more or 
less incontinence on coughing, 
laughing, and straming. There may Ix" residual urine in a dislo- 
cated bladder with corusequent cystitis. This is rare. 

Diagnosis. — There may or may not be evidence of bulging of 
the anterior wail of the vagina when the introitus vagina? i» 
inspected with th<^ patient in the dorsal position. Straining brings 
the anterior wall irito view, however, A curved sound urtrodurrd 
through the urc*tlira show.s the situation of the base of the bla<liler 
as determinetl by pa!j)ation of its tip under the anterior vagijial 
wall. The extent of the pnjlapse may Ixi estimated by examining 
the patient in the standing position and asking her to strain while 
the oxaminatii^n is made. In the knet-^clK^t position the cystocele 
diaappeai'S. In large cystweles the vaginal wall is thickened and 
lias the appearance of skin. In prolapse of the uteras it may be 
ulcerated* 

DiiSfereotial Diagnosis,— We tTiust flistinguish eystocele from 
cyst or other tumor of the vagina, hypertropliy of the bladder 



I -li^. — K Vfit<Jtvlc 



368 



DISEASES OF THE VAGINA 



wall in chronic cystitis, sub-urethral abscess, and true intestinal 
hernia of the vagina. Tumor of the anterior vaginal waU does not 
increase in size or tension on straining and coughing, it does not 
disappear on pressure or on putting the patient in the knee-chest 
position, filling the bladder has no effect on the size or elasticity 
of the tumor, and palpation of a sound in the bladder shows that 
there is something besides the walls of the bladder and vagina 
between the tip of the sound and the examiner's finger in the 
vagina. 

Hypertrophy of the bladder uxdl in chronic cystitis to the extent 
of forming a tumor in the vagina is rare. The diagnosis of cystitis 
by means of the cystoscope and examination of the urine, together 




Fig. 148a. — Diagrammatic Representation of Cystooele. 

with the symptoms of cystitis, point the way toward a differentia- 
tion. Palpation of the greatly thickened bladder by the finger 
in the vagina will settle the diagnosis. 

Sub-urethral abscess is diagnosed by placing a sound in the 
urethra and palpating the tumor in the vagina on the sound. 
In this way it will be plain that the urethra is not involved in the 
tumor. Besides, there are present in the case of the abscess symp- 
toms and signs of inflammation, and there is apt to be a minute 
opening of the abscess into the urethra through which pus may 
be forced on pressure. 

Anterior intestinal vaginal hernia is a rare condition in which 



DISPLACE5IENTS OF THE VAGINA 



369 



coils of small intestine occupy a sac formed by a pouch of pro- 
lapsed peritoneum between the front of the uterus and the bladder. 
Thi>s poucli projects under tlie anterior vaginal wall in the same 
situation a.s a cystocele. ' On pres^sure a true hernia disappeans 
with a gurgling sound, it disappears when the patient is in the 
knee-chest position, it is soft and doughy to the touch, and the 
coils of intestine may be palpated between a sountl in tlie bladder 
and a finger in the vagina, tlius showing a greater thickness of 
the intervening structures than in the case of cystocele. 



Regtocele 

Ilectoeele is a forward protrusion of the anterior rectal wall 
into the vagina, although the name is given to any !>ulging of the 
posterior vaginal wall, whether the protrusion rontauis the rectum 
or not. It is possible for the posterior vagina to become separated 
from the rectal wall, Ix^cause 
of the loose comiection of the 
two structures. As a rule the 
rectal wall is in the dislocated 
vagina. Reetocele is one of 
the concomitants of complete 
uterine prolapse. 

Etiology and Frequency* — 
Reetocele is eausetl by rupture 
of the jx^rineum and pelvic 
floor, by consequent subinvo- 
lution of the vagina, and by 
chronic overdistention of the 
rectum by feces and scybalous 
masses. 

The firm support^ ordinarily 
given to the anterior wall of 
the rectum during defecation, 
due to contraction of the levator ani muscle at this time, is lacking 
because of the injurj^ of this naiscle. Therefore the fecal mass 
covered by rectal and vaginal walls is jjushed forward into the 
vagina. Constant straining accentuates the faulty condition. 
Like cystocele, the development of a reetocele is a matter of 




149.— Hectoct'li\ 




370 



DISEASES OF THE VAGINA 



months and years, and the disease is frequent among the working 
classes for the same reason as in the case of cystocele. 

Symptoms. — ^The symptoms are a sense of fullness in, or pro- 
trusion from, the vulva, weight and dragging in the pelvis, and 
difficulty in defecation. Sometimes the woman is obliged to 
replace the rectocele with her fingers before she can empty the 
bowel, and in pronounced cases of rectocele there is apt to be 
rectal tenesmus and a feeling as if the rectum had not been emptied 
completely. 

Diagnosis. — Bulging of the posterior vaginal wall may be visible 




Fig. 149a. — Diagrammatic Representation of Rectocele. 



on separating the labia when the patient is in the dorsal position. 
Straining brings the wall into view and it recedes again when the 
effort is over. The physician, passing a forefinger through the 
anus, hooks it forward into the rectocele. This makes positive 
the diagnosis and differentiates separation of the posterior vaginal 
wall from the rectum, from cases of true rectocele. We must 
rule out cysts and other tumors of the posterior vaginal wall and 
true posterior vaginal hernia or enterocele. Both of these are 
palpated between a finger in the rectum and another finger in the 
vagina. A cyst or tumor is fluctuating or hard, and is felt as a 
distinct mass betwec^n the two fingers, whereas in rectocele the 
rectum and vaginal walls alone are lx»tween the fingers. 



INJURIES OF THE VACilNA 371 

In the case of cnterocelo the rloy^liy (vvl (>f intestine with trur- 
gling on pressure is to be made out, anrl, on placing the patient 
in tlie knee-cheat position the tuinor diHai>|x'ars5. 

Hernia or Enterocele 

True hernia or the descent nf h loop of intestine in a jioueh of 
peritoneum either into the recto- vaginal eellular tis-sue below 
Douglas' cul-de-.«ac, or into the cellular tissue between the uterus 
and the blad<ler^ is a rare occurrence. It is sufficient to note that 
eases have been reported and that the diagnosis is made by pal- 
pating the tumor and r-liciting the doughy feel eharaeterislie of 
intestine, by noting g\ngling noisc^s in the tumor when it is i)n*ssi*d 
upon, and by observing that the tuinor increases in size on straining, 
but disap|>cars when the patient is plaeeil m the knee-chest position. 
Such tumons must Ix* differentiated carefully from reetocele, 
cyhtocele, or tumor of the vaginal wall. (Set* tliese sections/) 

In very rare cases an enterocele has Ik'cu know^i to find its 
way to the vulva. In this situation it iinist b* distinguislied from 
inguuial hernia tliat hfLS reached the labium majys. Examination 
of tiie external alKlominal ring will show whi^ther the ring is free. 
Also it is to bt^ differc^ntiated from a cy^t of Bartholin's gland or 
other tinnor of the labium. In the ease of the enterocele it has an 
origin from alxive, has an impulse on coughuig, and ilisa|jpears 
w it h the patient in the knee-chest position, A tumor of the labium 
has none of these characteristics. 



p 



INJURIES OF THE VAGINA 



Injuries of tlu* vagina may U* <iue In (1) child! rearing, tn ttM> 
rapid exjjulsion of the head^ breech, or shouklers, or to pressure 
of tlie blailes of forceps^ (2) to coitus, wiiere there is disf)roimrtion 
betw^t^n the size of the penis and the vagina, ami too great violence 
is usi-il, (3) to miskillful instrutiientation, and (4) to a fall on a 
sliarp Ivwly such as a picket. 

(i) Child bearing. — A majority of injuries due in ehildlx»aring 
consist of lacerations of the ])erinenni, next in frequency are 
lacerations of the ut>[jer vagina, tlue to the extension of a tear of 
the cervix to the vagina, t^ometimes a circular laceration in the 



^ 



d 



372 DISEASES OF THE VAGINA 

upper vagina may separate the cervix partially or wholly from 
the vagina. Generally the tears of the vagina are longitudinal in 
direction. On one occasion I repaired immediately after a version 
an extensive longitudinal laceration of the anterior vaginal wall 
not involving the cervix. Lacerations of the vagina are more apt 
to occur where the vaginalVall has been narrowed by cicatrices 
or its elasticity has been impau-ed by disease. 

Lacarations of the Perineum and Pelvic Floor. — ^By this term is 
meant not only injuries of the perineal body so-called, — ^really not 
an anatomical entity, — but also damage to the structures compos- 
mg the pelvic floor. These are the levatores ani, — sphincter vaginap, 
sphincter ani, and transversus perinei muscles, and the following 
fascia) : posterior layers of the triangular ligament, — called also 
the transverse perineal septum, a strong mass of connective tissue 
and elastic tissue in which the muscles are inserted, the anal fascia, 
the recto- vesical fascia, and the deep superficial fascia. 

By conjoined recto- vaginal examination of a nullipara one 
determines that the tissues between the fingers are of the shape 
roughly of a triangle, with its slightly convex base the space on the 
skin between the anus and the fourchette, and its apex at the 
upper limit in the vagina of the lower anterior curve of the S 
formed by that canal in its course to the cervix. The tissues feel 
firm and elastic (the transverse perineal septum) and there is a 
distinct convexity upward (the patient being in the dorsal position) 
of the lower posterior vaginal wall. 

An attempt to evert the rectum through the opening of the 
vagina will encounter much resistance and cause pain to the 
patient. If, now, the patient is asked to strain it is noted that 
the anterior and posterior walls of the vagina already in contact 
are pressed more firmly together and that the perineum, — the skin 
surface between the vagina and rectum, — bulges outward, and 
the distance between anus and fourchette is increased. If, on 
the contrary, the woman is told to draw in the muscles it will be 
found that the anus and the skin perineum are lifted inward 
and upward toward the posterior surface of the arch of the 
pub(\s. 

By vaginal palpation pressure directed backward and on both 
sides of the middle line encounters definite elastic resistance (the 
levator ani muscles). If the patient is asked to contract the mus- 




INJURIES OF THE VAGINA 



cles they are felt to Iwrnmr rigitl. The significance of a laceration 
depends on the nuiulxT of structui'es involved and on the extent 
of the injury. 

In most first labors there is some injury of tlie fourvlietto in the 
metlian line. These sufierficial tt^arr^ are of little practical iniiJ^jr- 
tance because they clo not involve the supporting Btmetures of 
the pelvic flevor. If t!ie structures composing the ptTineum are 




vl»v^* 



Fig. 150. — Diagmmmatic Lofipttjdinal 5Ie<:liaii Section of the Pelviu, Showing 
Stnjctures uf the Pelvic Floor, (Dickinson.) 



rigifl and non-ela'^ic, as in the ease of oM primiparap, the tear is apt 
to be deeper and therefore of more si^rious iinpoil. 

Tears of the pelvic Hoor proper are of three sorts: (a) median, 
(6) lateral in one or both sulci, and (c) a combtnation of these 
two. 

(a) Median tears, if of any considerable depth, are apt to involve 
the spWncter ani muscle to a greater or less degree. To put the 
case a little difTert*ntly, a vast majority of the lacerations of the 



374 



DT8K\SES OF TITE VAGINA 



sphinrter aiii aro mfilian tears. In tin* rasv of rninjjlete laceration 
uf ihv perineum the iH^lvie Hoor prn|)(M- is not injured to the extent 
that its 8Ui>|iorting {jowi*r is li's.sinit'd, tlierefore we do not exiH*et 
to find the results of laceration of the pelvic floor m the form of 
cystoeele^ retroversion, and j>rolaj)se. 

Partial or complete los8 of control over the bowels is to be ex- 
p**ctrul after laeiTation of the sphincter ani. If only a portion of 
the fillers of the si>hincter are in juhmI tlie patient may lx.» able to 
control her bowels if they are constipated, but not if they are loose; 
or the retentive power over gas may be lost. 

Complete iMceratiitn. — ^Su|>i>nse the laceration is comi>ltHc. 
Inspe^ction shows a gai)ing vulva with the retracted ends of the 



FiG. 151* — Cojiipk'te iltMiiau Laix^ralmo of the Ferint^iim. Levator Ma My,^^,* - 
not Injured. (GilUam,) 

sphincter ani mnselc showing as a minute dimple on each side 
of the anus at the ends of the contracted, crescentic muscle. Tht* 
recto-vaginal sr^ptum, when not extensively torn, stretches al>ov<* 
as a teni^^ l)an<i across thi^ open anus, in which the bright red 
corrugated mucosa of tht^ rectum is seen. Unless the levator ani 
has l>een injured » the walls of the upper vagina an? in contact. 
If the laceration has not Ix^en comiil(»te a fingiT inserted into the 
anus estimates the amount of damage to the sphincter by noting 
the strength with which it gra^tps the finger 

(6) and (c). Lateral tears in the sulci are the common forms 



i 



of injury to tlic {irlvir ihmr. They art' the important ones from 
the point of view of the ditsiocation ami diseases of the |>e]vie 
organs whieli result if they are not rejjaired. 

The lateral tears injure the levator ani nuiscle. After the injury 
the muselc ends contract and carry with them the torn faseiie; 
s^jme of the injured structuirs are replacfnl by eonneetive tissue, 
and, in the case of tears reaching the surface^ by cieatrieial tissue. 
In the course of many years there may Ik* marked atrophy of all 
the stmetures composing the pehnc floor. The exact kind of 
deformity that results in any given case is determined by the 




Fig. 152,— IVrincuri! Lacoratt'^i 



in liuth Sulci 
((iiliiam/) 



Levator Am Musclos InjunMi. 



structures involved and the time which hiis ela|)sed since the 
receipt of the injury. Sundering the transverse perineal septum 
pemiits the transversus perinei muscles to contract and draw 
the edges of a wound to f»nth sides of the \^i!va. At an exami- 
nation of a fresh tear in the hours following delivery it is possible 
to get a fairly accurate idea of the structures involve*!, alth<jugh 
the swelling ami distortion r>f the tissues at this time nwler the 
determination not easy. By s<.»parating the labia ami sponging 




376 DISEASES OF THE VAGINA 

ofif the blood, the difference between the shining vaginal mucosa 
and the oozing raw tissue becomes apparent. The anterior vaginal 
wall should be held up against the pubes and the tears traced to 
their farthest limits. With a finger in the rectum the upper por- 
tions may be brought better into view. A good light and the 
patient on a table or on an ironing board on the edge of the beil 
are essentials to an exact diagnosis. After an interval of months 
and years we can not say exactly what has occurred at the time 
of injury. Dissection on the living, in the course of an operation 
undertaken for the purpose of repair, will not give us this informa- 
tion because of the abundant blood supply of the parts involved. 
Inspection of an old laceration in the sulcus shows a gaping vulva, 
vaginal walls apart, perhaps cystocele, rectocele, or prolapse, the 
perineum is flat and longer than normal because the rectum is 
displaced backward. When the patient strains the vaginal walls 
roll down instead of holding closer together, and the perineum 
between the fourchette and anus, instead of bulging, is con- 
cave. Palpation shows a groove in the sulcus and a lack of hard- 
ness here when the patient contracts the muscles of the pelvic 
floor. The perineal septum is always more or less injured in 
these cases, and palpation of the perineum with one finger in the 
vagina and the other in the rectum will make manifest that the 
convex summit of the perineal body, the top of the anterior S 
curve of the lower vagina, has disappeared and in its place is a 
depression. In many cases very little injury is apparent when the 
vulva is inspected because the skin has not been severed. The 
physician should be on the lookout for the "skin perineum" and 
not be deceived by it. By hooking a finger into the vagina the 
absence of the firm convex surface of the perineum will be appar- 
ent at once. A common form of laceration is a tear in one sulcus 
together with a tear in the median line. 

By the former we assume that the levator ani is injured and by 
the latter the transverse^ perineal septum. Often both sulci are 
affected and there is also a tear in the median line below. Too 
much can not be said of the importance of making an exact diag- 
nosis of the situation of the tear in every case of rupture of the 
pelvic floor, for in this way only can repair be intelligently carried 
out. 

(2) Injuries due to coitus are not frequent. Sometimes the first 



FOREIGN BODIES IN THE VAGINA 



377 



coitus causes a laceration of the hymen which extends to the vagina 
and there niay be serious hemorrhage. KaiK^ hai> caused severe 
and fatal injury of the vagina in children and also in women. In 
willing coitus whenever there is a large penis and a small vagina 
injury may occur if force is used. 

(5) Injuries due to unskiEful instrumentation are not very un- 
common. The violence is done soinetinies by the patient intro- 
ducing sharp instruments into the vagina in an vffoit to produce 
alx)rtion, and at others by the ignorant abortionist, also the un- 
skillful use of the obstetric forceps or other instruments may cause 
laceration, oftcni of serious import. 

(4) Falls on sharp bodies^ such as the picket of a fence or the 
handle of a pitchfork, have produced extensive and even fatal in- 
jm-ies. 

Hematoma of the vagina is a rare condition. It occurs both as a 
result of trauma and following labor, the latter being by far the 
more frequent cause. There is a collection of blood just under the 
mucous mendjrane and the tumor is dark in color and fluctuates. 



I 

I 



FOREIGN BODIES IN THE VAGINA 

Little girls may introduce foreign bodies in the vagina, just as in 
the other accessible ca\ities of the body, from a spirit of inquisi- 
tiveness. Thus pebbles, seetls, fruit- stones, i>encils, hairpms, and 
other objects have been removed from the vaginte of little girls. 
Older girls and women, esj>ecially the sexually perverted, have 
introduced the ends of canttles, pencils, and other things for pur- 
pascs of masturbation. S{^^>f)ols, rul:>l>i^r balls, sponges, pieces of 
cotton, and many other suKstances have bef*n taken from vagina^ in 
which they ha^j Imm placed in the hojje of preventing conception. 

The vagina has s<*rveil as a repository for smuggled and stolen 
property, such as jew(4ry, gems, and banknotes, and, in tlie case of 
the feeble-minded, a legion of strange articles have been secret^ 
there. The foreign liody most often found in the vagina is a neg- 
lected or forgotten pessary. As is well knowTi, a hanl- rubber 
pessary becomes incrusted with lime salts as soon as its pf»Iish is 
gone. The roughened surfact* chafes the mucous membrane until it 
ulcerates, Soft-mbber pessaries irritate the vagina more than the 



378 DISEASES OF THE VAGINA 

hard-rubber variety, as a rule, but not being so firm do not cut so 
far into the tissues. Pessaries have been retained for a long series 
of years in reported cases, and sometimes with resulting stenosis of 
the vagina. Sometimes a vesico-vaginal or a recto-vaginal fistula 
is caused in this way. Pin worms and round worms may inhabit 
the vagina. There is a foul discharge from the vagina if ulceration 
is present. The diagnosis of a foreign body is an easy matter when 
digital and speculum examination are made, attention having been 
attracted by the vaginal discharge. 

Gas in the Vagina (Garrulity of the Vagina.) — An accumulation of 
gas in the vagina that is expelled with a noise on straining or moving 
the body quickly from one position to another is a not very rare 
condition. Every gynecologist of experience has seen many cases. 
In the past it has been thought that such a condition was due ex- 
clusively to injuries to the pelvic floor, so that in certain positions 
of the body, as on the side, air entered, to be expelled later when 
the woman assumed the upright position. Although such a cause 
may be operative in some easels, the recent investigations of Klein- 
wachter, Taussig, and Veit (**Handbuch der Gynakologie," zweite 
Aufl., Bd. Ill, page 201) go to prove that the accumulation of gas 
in the vagina, a condition most often found in the puerperium, is 
due to a gas-foiming bacterium. The disease is thought to be alliwl 
to vaginitis eni{)hysematosa (see page 36i) and has been classeil by 
Veit as among the inflammations of the vagina. 

When the disease is due to injury of the pelvic floor with subin- 
volution coupled with weakening of the abdominal walls, the diag- 
nosis is not so difficult. If those conditions do not obtain, and it is 
due to a gas-forming organism, drying the vagina and packing it 
with dry tampons on which boric acid powder has been dusted 
will kill the organism and thus confirm the diagnosis. We must 
rule out n^cto-vaginal fistuUe in these cases, for gas in the vagina 
may come from the rectum. 

VAGINISMUS 

Vaginismus may Ix^ n^garded as a symjitom rather than a disease. 
It consists of a liyp<T(\^tlietie condition of the orifice of the vagina 
and is characterized by spasmodic and painful contractions of the 
levator ani and constrictor vaginte nmscles. Sometimes the irri- 



NEW GROWTHS OF THE VAGINA 



379 



lability extends Uy th<; tiiuscles of the thiglis or other sets of mujseles 
in the neighlxjrhtxxl of the vulva. 

Vaginistnus is a rare eonditiori found, as a rule, in yoiinp:t neurotic 
women and in tht^ ni^wly marriiMl. It may ovvui\ however, in 
women who have borne children. It may te def>endent on a local 
lesion, such as urethral earunele or inflammatiou of the vulva. 
Masiurbation, by overstimulation of the H*\ual organs, causes 
\'aginismus in some instances. I iK'ff tactual atterripts at coitus pro- 
duce in time erosions at the introitas and nervous excitability and 
dread of pain. A large penis and a small vagina may cause tonic 
spasms of the muscles of the pelvic floor. Castas are on RTOrd where 
the [xmis has become im])risoiKMl in the vagina by vaginismus so 
that it was necessary to administer an anesthetic to the woman 
lx*fore the couple coukl Ix' separated. The vagiim may be very 
sensitive, so that the slightest touch or even takhig a douclie causes 
contraction of the muscles, and a vaginal examination is impossible 
without an anesthetic, or it may be caused only by violent inter- 
course. The nervous system sufl'ers when vaginismus has existed 
for any length of time and various nerv^ous stigmata may Iw 
present. A vaginal examination will deterrnine the cause of the 
condition. If necessary a Seconal examinati<m with an anesthetic 
must be made. Vagiiiismus is one of the causes of dyspareunia,^ 
painful coitus. (See Chapter X., page 146.) 



NEW GROWTHS OF THE VAGINA 



The new growths of the vagina are: (1) cysts, (2) myomata, (3) 
sarcomata, (4) carcinomata. 

(i) Cysts.— Cysts of the vagina are the mast frequent of the 
tumors found in this organ. As a rule^ they art* f>etween the size of 
a jR^a and an English walnut, are single, and found on the anterior 
rathiT than on the posterior wall. Very large c}i?ts may develop 
in exceptional instances, and in such cases the cyst develops in the 
broad ligament; very rarely a series of cysts is found. A cyst of 
the vjigina ajipears as a l>luish- white ^ roimded eminence in the 
pink mucous membrane of the vagina. It is elastic to the kx^h If 
the cygft is situate<! superficially it projects more into the lumen of 
the vagina and is of a darker color liecause of its thin waOs: if it 




380 



DISE.\SES or THE VAGINA 



m^ 



is situated deep in ihv vaginal wall it projects less pronimently and 
is not so dark in color. 

Cysts of the vtigina mv due to (a) inclusions of epithelial tissue 
during o{>eration8 for the repair of lacerations of the perineum, 
or during spontaneous healing of 8ueh Injuries; (6) vaginal gland 

tissue, and (c) the remains of embryonic 
struotures, such as Gartner's and Miii- 
ler's ducts. Tlie inclusion cysts are 
generally found in the mughbirhood of 
the ptTineuiH, in the posterior wall, low 
down. These ai'e .small, spherical in 
s!ia[>e, have as contents mucus made 
turbid by desijuamate^d epithelium, and 
are lined with a layer of stratified 
s<iuanioys epithelium. Not much is 
knoi^ii about tlie cysts which arise 
from vaginal gland tissue. They are 
m frequent as compareil with the other 
two varieties, however. Cysts originat- 
ing in pc^rsistent Gartner's ducts are 
conii>aratively frequent, and are situ- 
ated in the lateral or anterior walls of 
the vagina. These cysts are more apt 
to be cylindrical in shape than per- 
fectly gloluilar, corresponding b their Icjug axis to the axis of the 
duet, arc filled with a clear straw-colored fluid, and are lined 
with cylindrical epithelium. 

A perststf^nt Milller's du(*t has k^en referreil to in the chapter 
on anomalies, A blinil end of a misplaceil ureter has been known 
to form a cyst of the vagina. 

The diagnosis offers little difficulty. C}'st.ocele, urethrocele, and 
rectocele must Ije rulei! out, also other tumors of the vagina. An 
arterio-venous aneurism has teen mistaken for a cyst of tlie vagina, 
also vaginal hernia, or eol lection of blood in a double vagina. A 
sound in the urethra or bhidder wiJl assist in excluduig urethrocele 
and eystocele, and a finger in the rectum, rectocele. 

A eystocele or rectoc<4e should increase in density on straining, 
whereas a cyst does not. A vagina! hernia should transmit an 
impulse on coughing and lias a characteristic doughy feel. It tlis- 



Fic3. 153. — Tndusion Cyst 
of Vagina Occurring Three 
Years after Repair of a Peri- 
neal Tear, (Cnllen.) 



« 



I 



NEfW GROWTHS OF THE VAGINA 



381 



?V 



appears when the patient is placed in the knee-chest position. An 
aneurism should have a tfirill. Tlit* characteristics of double vagina 
have bx'n d<*^cribed in the .seetii»n on anomalies. 

Ecliinoeoi'cus cysts of t lie vagina are very rHi*c and are generally 
tlue to echinocoecus colonies in the 
messometrimn burrowing in the 
rectn-vaginal septum. 

(2) Myomata. — Myomata or fi- 
broids of the vagina are rare. 
Some seventy authentic cases have 
been rt*pcjrted in the hteratm-e, being 
found in most cases in women Ix*- 
tween forty ami fifty years of age. 
They occur as small, s|iherical^ hard, 
nodular tumors, seldom over two 
inches in diameter, projecting from 
the vaginal wall into its lumeru 
They are usually single, but may Ik* 
multiple and are not associated witli 
fibroids of the uterus, although a 
case where Ijoth existeil in the same 
patient has tx^en n^ported by Fabri- 
cius (ZeniralblaU fur Gynakolmjie^ 
1908, No, m, 1191) and another by 
KelJy and CuUen (*' Myomata of the 
Uterus^^* page 440). The tumor is sessile and has a tibrous 
capsule of its own se|)aratjng it from the surrounding tissues. 

The etiology i*f these tumors, just as in the case of fibroids of the 
uterus, is mikoown. They are apt to be* the seat of etlematous 
degeneration. 

The diagnosis is generally easy, the fluctuating character of a 
vaginal cyst serving to rlistioguish it from a myoma, anil in the 
ease of sarcoma and carcinoma the mucous membrane covering 
the tumor is involved, whereas in myoma it is not. The hard 
character of the tumor serves to distinguish it from cystocele, rec- 
tocele, or hemia. 

(3) Sarcomata. — Sarcoma of tlie vagina Is of two sorts, {a) 
sarcoma of the vagina in children^ and (A) sarcoma of the vagina 
in adults. 



W: 



Fto, 154, — Cyst of Anterior 
Vaginat Wall Probably Due to 
Occltiflion of G&rtaer's Duct. 
(Cullen.) 



382 DISEASES OF THE VAGINA 

(a) Sarcoma of the vagina in children is of doubtful etiology, but 
has bcc^ii observed very soon after birth. It generally develops in 
the first year of life and is fatal within a year or two. In one case 
reported the child lived to be six years old. About forty cases of 
this disease are on record. The disease is characterized by the 
development of vesicle-like polypi of a dark red (hemorrhagic) and 
pinkish-gray (translucent) color, arranged in racemose clust<jrs. 
In the beginning of the disease the first appearance is a polyp, usually 
attached to the anterior wall of the vagma. In five out of the six- 
teen of the twenty-six cases analyzed by Starfinger ("Sarcom der 
Vagina bei Kindem," 1900) however, the disease began on the 
posterior wall. Its surface is smooth and it resembles a mucous 
polyp of the uterus. From this polyp there develop in the course of 
time, weeks or months or even years, proliferations of cystic pol)q)i 
until they fill the vagina and project through the vulva. The disease 
is apt to involve the bladder at an early date, then the cervix and 
uterus, and finally the peritoneum. Metastases are infrequent, the 
growth extending mostly by continuity and generally forward into 
the bladder and peritoneum and not backward into the rectum. 
Histologically the growth consists of round and spindle-shaped 
cells, also giant cells and strijx^d muscle fibers. The diagnosis 
before the disease has progressed extensively is very difficult. A 
vaginal discharge in an infant should lead to a speculum exami- 
nation, a Kelly cystoscope with a reflected light being the best 
instrument for tliis purpose. 

(b) Sarcoma of the Vagina in Adults. — Fifty-two cases of this 
disease are on record. It is a disease of later adult life, few of the 
cases Indng under forty years of age. Here, as in the case of the 
chikl, the disease b(»gins as a polyp most commonly, although 
instances of its starting as a diffuse infiltration are reported. It 
appears to lie latent for a considerable time, just as with the child. 
The j)rimary lesion may be on either wall of the vagina, and it 
progn^sses in its development as a ring-like infiltration so that the 
vagina is narrowed, or it grows as a diffuse tumor of one wall. 
Ulceration occurs. The disease does not often penetrate the vesico- 
vaginal or recto-vaginal s(^pta or extend largely, but metastases 
to other organs are formed relatively early. Plistologically the 
tumor is madc^ up of small round cells, spindle cells, and giant cells, 
but not striped muscle fibers. Melanotic sarcoma has been report- 



NEW GROWTHS OF THE VAGINA 



383 



*h1 in three cases. The apix^arance of a potyp situatt^d on tlu' 
vaginal wall, usually with a broad base and of hrni consistency, 
should excite a sus]>it'iori of san^onia. Mirrnsrnjiic rxuinination 
of the remo\t*(l polyp will dit^tinguish aarconia from myoma or 
carcinoma. 

(4) Carcinoma of the Vagina. — Carcinoma of the vagina is eec- 
omlary to cancer of thr uteriLs, ui whii-h evfiit it is relatively com- 
mon, or it i.s primary, when it is comimrativc^y rare. iSchwarz 
observed 84 cases of primary cancer of the* vagina among 35^807 
gj'Tiecological patii*nts, or somt^thing over twotenths of one |kt 
cent. It fornus abjut one per cent of all carcinoniata of the gen- 
erative organs. Primary cancer oftiw vagina Is a dist^ase of advanci'd 
life, but nmy occur a.s early a.s the twenty-sixth year; it occurs only 
in womi:n wlio have borne (diiitlren and is more often fomul in the 
posterior wall When seen *^arly it is a no^lule an ineli or an iiirh 
and a half in diameter, Tlie CMJges art^ sharply defint^l, infiltratHi, 
and injecttul Thi' surface soon becorntn? necrotic and ulceralrd 
and may exJiil)it ijajiillary elevations. The noclule is firndy t^m- 
be<ldcHl m the surrtMinding tissues after the very earliest stages. 
The disease extenils extremely rapidly Ixjth sui)erricial]y and dei»ply, 
ami if the lower jjortion of the vagina is infect(Hl the inguinal lymph 
glantls are mvolved, Tlie ilisi-ase tends to extend to the reetum 
more often than to the Ijlaikler and it nmy reach to the vulva; it 
originates in the s<|Uumous epitlielium and has all the ehara<ier- 
istics of stfuamous-eelliHl cancer (siH^ Cancer of tlu^ Uterus. |>ag(^ 267), 

In getting a s|>eeimen of tissue for niicrosfoiiic examination the 
dee[XT tiasuc*s must Ix' excised bn^ause the superficial portions 
consist usually of inflammntory products only. The synjj4oins 
in the early stages are bleeding from the vagina, on coitus espe- 
cially, also a watery vaginal discharge. 

In making the diagnosis we must rule out secondary carcinoma 
of tlie vagina. Tliis is done by discovering cancer of the eervix, 
cerv^ieal canal or fviudus uteri, or cancer of the rectum or bhiddcT, 
Carcinoma in thes«:^ situations must bc^ rigidly exchide-d Ix'foi-e piTi- 
nouncing the dist^ase i)rimary iu ih(^ vagina. Myoma is excludetl 
by the jihysical a[jpearances of myoma and by tlie microscojx*. If 
a primary caneerous area lies lx4iind a stenosis of the vagina the 
diagnosis is more tlifficult. Inflammatif»ns of tin* vagina with ul- 
cerations arc differentiated l>y the absence of infiltration under the 




384 DISEASES OF THE VAGINA 

abcess. If an ulceration caused by an ill-fitting or neglected pessary 
does not heal rapidly a portion should be excised for microscopic 
examination. 

There have been reported a case or two of primary chorioepUhe- 
lioma of the vagina, and venereal warts in conjimction with condy- 
lomata of the vulva occasionally occur. 



FISTULiE OF THE VAGINA 

An opening between the vagina and the surrounding hollow 
viscera is called a fistula. Of such fistulsB there are five sorts: — 
(1) Vesico-vaginal, (2) Urethro-vaginal, (3) Uretero-vaginal, (4) 
Recto-vaginal, and (5) Entero-vaginal. The last is extremely 
rare. For the sake of completeness we must mention a communi- 
cation between the vagina and a pelvic abscess, or the peritoneal 
cavity, openings made, as in the case of (5), filstula into the in- 
testine, in the course of operations. 

Vaginal fistulas are caused by sloughing of the vaginal walls 
due to prolonged pressure of the child's head during labor, by 
injuries from obstetric instruments, by ulceration due to pessaries 
and other foreign bodies, or by ulcerations from foreign bodies in 
the bladder. They result also in the late stages of carcinoma of 
the cervix, vagina, rectum, and bladder, and following operations, 
especially hysterectomy. In the last case and also when a vesico- 
vaginal fistula has been formed by operation, nature closes the 
opening, generally in a short time. 

Vesico-vaginal fistula is the most frequent of all the forms of 
vaginal fistulse, although not nearly so often met with as in the 
olden days before the art of obstetrics had been perfected to its 
present high degree of excellence. The vaginal and bladder walls 
are involved in varying extent. Almost the entire base of the 
bladder may slough away, leaving the orifices of the ureters exposed 
in the edge of the fistula, or the opening between the bladder and 
vagina may be no larger than a pin's point. The symptoms arc 
leakage of urine* from the vagina, and, imless great care is main- 
taincKl by the patient to keep dry, excoriation, redness, and sore- 
ness of the vulva, perineum, and thighs. The amount of urine lost 
will depend on the size of the opening and on the retentive power 



of the vagina. Sometimes urmo is retained in the vagina while the 
patient is recumljcnt, the pelvic floor being uninjunxl and the in- 
troitu8 small. Often when the fi.siula i^ t^inail the i>atit!nt may void 
a portion of the urine through the urethra and the rest will escape 
tlu"ough the vagina. 

The diagnosis is maile by the history of incontinenee and by the 
physical examination. The digital touch, if the fistula Ls large, will 




Fio* 155. — SchiTue uf the Different iSorts of fictiitd FisLoliK, not Including 
Fistula-in-Ano. (Gillbm.) 1. U re thro vagina I. 2, Vesico- vaginal. 3, Ilecto- 
vaginaL 4. Vesico-ut^rine. 5. Ur«?tero- vaginal. 6. Entero-vaginaL 

indicate the size and situation of the fistiila. The patient is plaeefl 
in the Sims position and a Sims speeulum intnidueed. Inspection 
shows the size» sha|>ej and situation of tht* fistula. A sound or ] irol^e 
passed through the urethra may be made to appear tlirough the 
oix^ning in the vagina. In larger fistuhe the bladder wall is apt to 
be mucti ijijected (cystitis) and often incrusted with lime salta. 




386 DISEASES OF THE VAGINA 

These must be removed gently. Vesico-vaginal fistula gives a fine 
opportunity to insjject the bladder and to catheterize the ureters. If 
the fistula is very small and there is doubt as to its situation, the 
patient is placed in the dorsal position and the bladder is filled with 
milk and water. Examination of the cleansed vagina through a 
duckbill speculum will show the point at which the white milk 
leaks through the fistula. 

Uretero-vaginal fistula is detected in the same manner. The 
bladder is filled with milk and water and it is noted that clear urine 
and no milk collects in the vagina; measure the bladder urine and 
that which gathers in the vagina, and, if the two kidneys arc secret- 
ing an equal amount, it is possible, by finding that the two quan- 
tities are the same, to decide that all the urine from one ureter 
escapes into the vagina. The sense of smell is a great help in de- 
tecting the presence of urine, for in some instances the differentia- 
tion of watery fluid coming out of the uterus or the peritoneal cavity 
from urine is not easy. To aid in distinguishing urine in crises of 
vaginal fistula it is sometimes of use to give the patient five drops 
of doubly distilled turpentine on a lump of sugar three times a 
day. It imparts the characteristic odor of violets to the urine. 
Methylene blue, one to two grains every four hours given by the 
mouth, renders the urine a bluish-green color. The colored urine 
may be seen to escape from a fistula. 

Urethro-vaginal fistula is a rare variety of fistula due to syphilitic 
or malignant ulceration or operation on the urethra. The opening 
between the urethra and vagina is generally small and is situated 
in the upper course of the urethra. There is no incontinence of 
urine imless the fistula involves the neck of the bladder. The 
diagnosis is made by passing a probe into the urethra and through 
the fistula. For fistulie involving the bladder and ureters see also 
Chapters XXIV and XXV, pages 474 and 492. 

Recto-vaginal fistula results in the late stages of cancer of the 
cervix and also in the case of neglected ixjssaries and imperfect 
union of a lacerated perineum. Rarely this fistula results from 
syphilitic or tubtTCulous lesion of the vagina. The opening is 
generally small in size. 

The symptoms are the escajx^ of flatus, and also more or less fluid 
feces, into the vagina. Vaginitis and vulvitis are apt to result from 
the irritation caused by the fecal matter. 



FISTULiE OF THE VAGINA 387 

The diagnosis is founded on the history, and on the examination. 
The patient is placed in the dorsal position and the anterior vaginal 
wall raised by a Sinis speculum. If the fistula can not be seen a 
probe is passed in the most likely spots and if it enters an opening 
which connects with the rectum its point may be felt by a finger in 
that organ. Also, one may inject the rectum with milk and water 
and note its escape into the vagina. 

Entero-vaginal fistula is rare. It results generally from a surgical 
operation. The presence of feces in the vagina, the exclusion of an 
opening into the rectum by means of inspection of the rectum 
tlirough a proctoscope, the character of the fecal matter (chyme), 
and finding the opening of the fistula in the upper vagina on in- 
spection and probing with the patient in Sims position, will establish 
the diagnosis. For fistula-in-ano see Chapter XXVI, page 516. 



CHAPTER XXI 

THE DIAGNOSIS OF DISEASES OF THE VULVA 

Anatomy, p. 388 : Age changes, p. 391. 

Congenital Anomalies, p. 391: Malformations of the vulva as a whole, 
p. 391. Development of the external genital organs, p. 392. Anomalies, 
p. 393. Malformations of the clitoris, p. 393. Malformations of the 
labia majora, p. 394. Malformations of the labia minora, p. 394. Mal- 
formations of the hymen, p. 396. Imperforate hymen, p. 396. Hermaph- 
roditism, p. 399. 

Injuries of the vulva, p. 400. 

Inflammation of the vulva, p. 402: Simple or catarrhal ^'ulvitis, p. 402. 
Gonorrheal vulvitis, p. 402. Diabetic vulvitis, p. 403. Thrush, p. 403. 
Elephantiasis, p. 404. Pruritus vulvse, p. 404. Kraurosis vulve, p. 404. 
Edema and gangrene, p. 405. Varix, p. 405. 

Venereal lesions of the vulva, p. 406; Chancroids, p. 406. Chancre, 
p. 406. Mucous patches, p. 407. Condylomata, p. 407. Gumma, p. 408. 

Tuberculosis of the vulva, p. 408. 

Cysts of Bartholin's gland, p. 408; Abscess of Bartholin's gland, p. 409; 
Differential diagnosis of cyst and abscess, p. 412. 

Labial Hernia, p. 412. 

Benign tumors of the vulva, p. 413. 

Malignant tumors of the \'ulva, p. 414: Cancer, p. 414; Differential 
diagnosis of cancer, p. 415. Sarcoma, p. 416. 



ANATOMY 

The tiTin vulva is ai)plicd collectively to the structures often 
called the external genital organs, and includes: the mons veneris, 
the labia majora and minora, the clitoris, the vestibule, and the 
hymen. 

The Mons Veneris. — ^The mons veneris is the eminence in front of 
the symphysis i)ubis. It is formed by a collection of subcutaneous 
fat and is covered with coarse hair, gencTally of the same color as 
the hair of the head. The upper limit of the hair is a horizontal 
line, differing from the male pubic hair, which is continued up- 
ward along the linea alba in a V shape. Below, the hair is con- 
tinuous with th(» hair on the outer surfaces of the labia majora. 

The Labia Majora. — These are two thick, parallel folds of skin 

388 



ANATOMY 



380 



extending from the mons veneris neai'ly to the anus. They are 
wider above and grow thinner a,s they approach the perineum 
where they are lost. Each fold is called a liilnum iiiajus and the 
o[>ening where the two meet in the midtlle hue i.s caWvd the pu- 
drndal slit (rirna piidench). The posterior limit of the slit is a 
transverse eutantHms fold calleil the fourchette, the de])ression 
Ix'twetm this anrl tfie \}im' of the hymen being the fossa navicularis. 



FiG> l^^^Diagram of the VuJva. (DickinsonO 

The labia majora are pigmented more than the surrounding skin 
and the outer surfaces contain sebaceous glands and an? covercxl 
with more or less hair, the hair becoming scanty and short^ to- 
ward the posterior parts. The inner surfaces of the labia majora 
are smooth, and the tliin skin covering them resend>les nmcous 
mi^mbrane in the \nrgin, but is harder in the parous woman. The 
outer ends of the rountl ligaments become lost in the upper por- 




390 DISEASES OF THE VULVA 

tions of the labia majora, which are made up of fat and connec- 
tive tissue. 

The Labia Minora^ or Njrmphss. — ^These are two thm, pink, deli- 
cate folds of skin extending from the frenum of the clitoris above, 
downward to be lost on the inner surfaces of the labia majora at 
about the level of the opening of the vagina. They are developed 
from the margins of the genital cleft. They have no hairs but 
abundant sebaceous glands. Each fold is a labium minus, and 
the two labia may be asymmetrical. In the virgin the lesser labia 
are entirely covered by the greater labia, but imder abnormal 
conditions the nympha3 may project beyond the labia majora, 
and in this case they are pigmented. 

The Clitoris. — ^This is a rudimentary penis developed from the 
genital eminence, but it is without a urethra traversing it (see Fig. 
157). It is situated between the labia majora and is concealed by 
the upper portions of these structures, it is about an inch and a 
quarter long, and arises from the pubic arch by two crura, which 
unite to form the body of the clitoris. At its tip is a glans, which is 
covered partially or wholly by a prepuce, that, coming from above 
aqd partially encircling the glans, is prolonged downward into the 
labia minora. The clitoris is made up of erectile tissue and the 
glans is covered by a very sensitive epithelium. At the base of the 
glans are sebaceous glands which secrete smegma. 

The Vestibule.-^The space between the clitoris above, the en- 
trance of the vagina below, and the nymphse on the sides is the 
vestibule. It is developed from the urogenital sinus, is, roughly, 
triangular in shape, and is pierced in its centre by the external 
orifice of the urethra, (meatus urinarius) which presents a longi- 
tudinal slit closed by two little lips (labia urethrae) which form a 
slight elevation above the surface of the vestibule. 

The Hymen. — ^This is a thin, circular, white or light pink, per- 
forated membrane which separates the vulva from the vagina. 
It is made uj) of connective tissue and elastic fibers and is covered 
on both sides with stratified epithelium. Its shape, thickness, 
and even its situation vary in different cases. The opening into 
the vagina (introitus vaginao) is generally in the anterior part; 
it may be ring-shaped (annular), admitting the tip of the forefinger; 
this is the commonest condition, or it may be cribriform/ fimbriate, 
horseshoe-fihaped, septate or linear. The tissues of the hymen 



C30NGENITAL .\KOMALlES 



391 



may bo tough and resistant, though generally friable and torn with 
the first coitus or even by vaginal examination, always by parturi- 
tion. The remaijis of the torn hymen are calk*<i canineuhe myrti- 
formes. In the infant and embryo the hymen projects fonvard 
into the cleft between the labia in the form of two apposed longi* 
tudinal hps, (See Figs. I6,"i to 170,) 

The Glands of Bartholin. — These glands furnish a clear, glair};* lu- 
brieating mucus for coitus and for the delivery of the child during 
lalx)r. They arc two in number, each is about the size of a large 
pvB. auil is situated at the side of thc^ jX)sterior part of the vaginal 
canal in tiie sphincter vaginae muscle. The opening of the canal 
of the gland is a minute pin-point hole to be found in the |X)sterior 
portion of the inner surface of the laljium majus. In wonif^n who 
have lx>rne children it is just outside the last and oiipermost car- 
unciiJa myi-tiforinis. 

Age Changes 

Infancy.— In infancy there is no visible hair on the mons, and 

the labia majora are rounded and firm, the labia minora projecting 
bci^ween tlieni as slightly elevated, pink fokis. (See Fig. 203,) 

Puberty. — At puberty hair grows on the mons and the outer 
surfaces of the labia majora, the latter lx*coming pigmented antl 
increasing in size so that they conceal the nymphie. The nymi>hie 
may grow larger after pol)erty» and if they do, the exposed {>arts 
become pigmented and of coarser texture. Enlargement of the 
nvTiipha* has lx?en ascril>ed to masturbation, and it is likely that 
sucli is sometimes the case, though this is not the only cause. 

Old Age. — The hair on the mons and labia majora becomes 
gray and is shetl soon after the hair of the hejuL After the meno- 
pause the mons loses its fat gradually and the labia sfirink so that 
in old age the orifice of the \ulva ga}}es. The hymen if uidjroken 
shiinkjs, and the introitus vaglme is narrowed in any event* 



r 



CONGENITAL ANOMALIES 



Malforations of the Vulva as a Whole,— True congenital anom- 
alies of the vulvii, such as complete atresia of the vulva, arc very 
rare and occur for the most part in nun-viable fetuses. There are 




392 



DISEASES OF THE VULVA 



on record, however, one ease of double \Tilva in an adult, and many 
cases of infantile vulva where the labia majora and minora were 
small and flat, the introitus narrow, and the mons veneris not 
prominent and poorly providwl with hair. Such a condition is 
usually associated with poorly developeil general physic]ue. Pro- 
eoeious flevelopraent of the \ailva is found sometimes in conjunction 
with precocious menstruation in very young children. In these 
cases the breasts also show alinormal development. In the chapter 
on diseases of the vagina, page 356, I have referred to the not in- 
frequent occurrence of a normal \^Iva and normal body form 



Ghm (hlbri^i^^^ 



Gfotkd 



Otntfalfoki 







AriMS 



FiQ. 157. — ^The External Genital Organs at the Beginning of the Third Month 
of Fetal Life. (After Keibet) 



associated with a rudimentary uterus ami vagina* An apprecia- 
tion of the steps in the development of the several parts of the 
urogenital system is a necessity for the proper understanding of 
the difTerent congenit^al malformations of the external genitals. 

Development of the External Genital Organs. — At the enil of the 
first month of intra-uterine exif^tence there is developed in the 
outer siuf ace of tlie caudal region of the embryo a depression in the 
skin (Fig. 158), which grows dei*i>er mitil it reaches the allantois 
and rectum to form the cloaca (Fig, 159). Alxiut this time ap- 
pmrs the genital eminence above the cloaca, flanked on civch side 
by a fold of skin. The genital eminence in the female becomes 
later the clitoris^ and the folds of skin the labia majora, the njmiphjF 
Ix^ing developeil on their itmer siuface^. (See Fig, 157.) Figure 



CONGENITAL AXO!^ULIES 393 

160 shows the iliffcrLmtiation of the bladder and reetuni from 
tlie allantois and hin<:i gut re.s|K»etively, and the beginning of tht^ 
fnnnation of the jxTineuni by the downward extension of the 
jjerineal septum lx*tween the reetutn and the yrog:enital sinus, 
whieh has been formed by a union of the ducts of Midler and tlir 
eloaea. The prortodeumj the pot^erior portion of the invagination 
of the skin that is to form the anus, is now diffejvutiated In 
Fig. 161 the uretlu-a has tx^n formed and a septum divides the 
urinary from the genital tract. Figure 162 (at about the end of 
the fourth month) shows the vagina, although not yet with a canal, 
ilevelopefJ from the duets of Miiller and se^paratal by the hjmien 
from the vulva. The perineum lia,"* its mature shape and the anus 
now opens backwarrh The vestibule, the chtoris, and both sets of 
labia are already formed, although they do not assume their final 
shajx: mitil the fifth or sixth month. The externa! genital organs 
are at birth much more comj>!etely developed than the internal 
organs, whieh remain in a more or less rudimentary condition until 
the child is eight or ten years old. 

Anomalies* — Persistence of the Urogenital Sinus, — This is most 
often met with as an opening of the anus into the vagina, ** anus 
vaginalis '^ so called, in which there is incontinence of feces IxM*ause 
of the absence of the spliincter ani muscle. There is met with rarely 
a hi/pospadiaSj or a connection of the iwethra with the vagina high 
up, the vestibular canal lx4ng long. Another form of hypospadias, 
also rare, is the condition where there is no in-ethra and the bladdiT 
ojxjns directly into the vestibular canal. In thi»se cases therc^ is of 
necessity incontinence of urine and the blmlder opening can Ix^ 
Been in the anterior wall of the vagina. 

Occasionally a casi> of persistent cimeu is met with, the jxTineal 
septum and the sphincter ani not beting developed. Incontinence 
of feces exists in such cases. 

Matformadons of the Clitoris* — The clitoris may be absent, it may 
be small, it may Ix* hypcrtrophied, it may Ix* cleft, as in episfmdm,s, 
or the prepuce may be adherent. Absence o( the clitoris is an 
extremely rare occurrence, and so is cleavage of the clitorLs, but 
the organ is found very small not infrecjuently, and large cjuite com- 
monly. Sometimes the clitoris attains the size of a small pyerile 
jxnis. Such a condition has no clinical significance and requires no 
treatment unless it interferes with coitus, — an unusual happening. 




394 DISEASES OF THE VULVA 

An adherent prepuce, on the other hand, may be the source of 
sexual irritation and conduce to masturbation, and in children 
may be the cause of enuresis, some writers even attributing the 
existence of symptoms of grave derangement of the general ner- 
vous system to this as a cause. All women who apply for gyncs 
cological treatment should be examined with reference to the 
adhesions of the prepuce. The prepuce should be pushed upward 
with two fingers until the glans can be distinguished. By the use 
of gentle pressure, aided if necessary by the flat end of a surgical 
probe, the prepuce may be separated from the glans. Hard, white 
specks of retained smegma not larger than a pin's point are gen- 
erally found under the adherent prepuce. Some authors maintain 
that adhesion is a condition normal to the prepuce in both sexes. 
The number that are found to be adherent in girls and women, if 
every case coming under observation is examined for this con- 
dition, has been surprisingly large in my experience, and my own 
view is that adhesion of the prepuce in the girl and woman plays 
a much less important role in the causation of symptoms than in 
the boy and man. 

Malformations of the Labia Majora. — ^The following malformations 
have been described, although all must be regarded as extremely 
rare. Absence of the labia, rudimentary labia, multiple labia, 
hypertrophy of the labia, and adhesions of the labia. The only 
ones that require comment are multiple and adherent labia. The 
former consists of longitudinal division of the labia into several 
folds of skin instead of one, and the latter is a part of apparent 
vulvar atresia. If the closure is complete the child is non-viable. 
Generally there is a small opening anteriorly through which mic- 
turition takes place. 

Malformations of the Labia Minora. — ^The same malformations 
as in the case of the labia majora have been met with. The two 
that need description are hypertrophy of the labia and adherent 
labia. Hypertrophy of the nymphce is by no means rare. It reaches 
a stage of extreme development in the *' Hottentot apron," so- 
called, in which the labia extend downward some seven or eight 
inches between the thighs. This condition is unknown among the 
women of civilized races. A moderate degree of hypertrophy is 
not uncommon and is of no importance unless it interferes with 
coitus. Adherent labia represent inflanmiatory affections during 




FiQ. 160.- The Blaiider Ib 
Formed, also the Be^nning of the 
Urethra and the Vagina, Both 
Dpenin^ intrj the rmgenital Sinus. 
The Rectum opeos Separately 
into the Froctodeutn. 




Hfsn^AiSJ 



%rtn€**^ 



FfQ. 1B2. — Complete Development. The Urogenital Sinus Has Be- 
(Xirae the Vestibule. The Hymen nearly Closes the Opening of the Viigina, 
which Has Become Enlarged. The Kectum is more Capacious and the 
Anus Opens Backward Posterior to the fully Developed Perineum, 



FiOB. 158- U>2. Five Diagrams of Longitudinal Mej^ian Sections of 
Elf BR Y OS, Illustratinq the Btjlqes of Development up the GbnitaIj 
Okoa^s. (After SchroederJ 395 




396 DISEASES OF THE VULVA 

fetal or infantile life. The union is generally incomplete? and 
there is an opening through which urine can escape. Imme- 
diate division of the two labia is demanded if there is no open- 
ing when a child with this deformity is bom, otherwise it is 
non-viable. 

Malformations of the Hymen. — ^Authorities are divided as to the 
structures from which the hymen is developed. Pozzi's view of 
its development (" Traits de Gynecologic/' quat. ddit'n, p. 1383) 
seems as near the facts as any. It is that the hymen is developed 
in the fifth month from both the vagina above, after fusion of 
the Miillerian ducts, and from the vestibular canal, — a vestige 
of the urogenital sinus, — below. Gellhom {Amer. Jour. Obstet., 
Aug., 1904, p. 145), who has studied this question most carefully, 
thinks that the indications point to the hymen being derived from 
the Miillerian ducts exclusively. 

The hymen has never been found absent by competent observers. . 
As has been stated in describing the anatomy, the form of the hy- 
men varies much in different individuals, also its thickness. Of 
the different forms in which the hymen is found, the fimbriate or, 
denticulate, the sei)tate, the cribriform, the annular, the linear and 
the crescent, the annular and crescent-shaped hymens are the most 
common. The hymen may be so tough and resistant that it is not 
ruptured by attempts at sexual intercourse, on the other hand it 
may be so dilatable that it stretches to accommodate the penis with- 
out tearing. The rule is that it is generally torn by intercourse, and 
always by parturition. Cysts and solid tumors of the hymen have 
been described, but they are excessively rare. 

Imperforate Hymen. — ^The opening in the hymen may be ex- 
tremely minute and yet pregnancy may ensue. A case has been 
recorded by H. L. Horton {Boston Med, and Surg, Jour., vol. 82, 
p. 33) of a patient who was in labor with a hymeneal opening 
measuring only one-sixteenth of an inch in diameter. From the 
most recent researches the view has gained ground that imper- 
forate hymen is a misnomer, the condition being one really of 
atresia of the vagina, for in many of the cases recorded after the 
liberation of retained menses a hymen has been foimd outside the 
obstructing membrane. In other words, the lower end of the va- 
gina, which is a solid structure in the early stages of development 
after the fusion of Miiller's ducts and before the canal is formed. 



398 



DISEASES OF THE VULVA 



remains impervious iii the sKlult. Be the cause what it may, the 
result is a damming up of the uterine secretions with msuJtiag 
hematocolpot^, hcmatometra and even hematosalpinx. 
The vulva of every female infant should be inspected by the 
obstetrician and the patency of the orifice 
of the vagina determined bypassing into 
it a catheter. Most easels of imi>erforate 
hymen are not discovered until puberty, 
in rare instances the malformation has not 
been suspected untU early marriage. There 
may l>e few symptoms, and these nothing 
more than a sense of wxnght and fulhic*ss in 
the pelvis. As the accumulated blood in- 
lll creases in amount the patient may experi- 
ence eolicky pains in the abdomen and in- 
terference with micturition and defeeation- 
Anienorrhea, w^hen the body shape and the 
psychic changes of puberty amiounee the 
presence of that state, should lead to a 
local examination, especially if there is 
a menstrual moli- 



FiG* 17L— Hemato- 
colpos, Gauseci by Aire- 
Bia of the Vagina or 
Imperforate Hymen. 



men. 
[>ifignods of Im- 
perforate Hymm,— The diagnosis n^sts on 
the physical examination . Inspection 
show^s a bulging in the region of the in- 
troitus vaginie wliieh is of a bluish tinge. 
The urethral orifice is dilated. Recto- 
alxlominal pali)ation reveals the presence 
of a fluctuating mass in the region of the 
vagina; if the case is an eai'ly one, the 
vagina alone may be ililated, if a later 
case the uterus, or the uterus and t!ie 
tubes are enlargetl (see Figs. 171, 172 and 
173.) The utmost gentleness should l)e 
employed antl it is wise not to make too 
exact a ciiagnosis because^ of the danger of 
rupturing the tubes, should they be distended. A more precise 
finding is gained after an anesthetic has been administered, and 




Fig . 172.— Heiiia(uin>ljK>8 
and Hemat4jinetra. 



CONGENITAL ANOMALIES 



399 



this ouli] not bo given until the preparations have been made 
for evacuating the fluid. 

Hermaphroditism. — Hermaphroditism (Hermes and A|>lirodite), 
the union of the two sexes in one indivitlual, is a term generally 
used to de.serilx^ a person whojso external genital orgiuis partake of 
the eharacteristics of both sexes. Every embryo is in the begin- 
ning potentially both male and 
female; some prepomlerating in- 
fluence ileterminhig the deve)o|> 
ment of the Wolffian or the Miil- 
lerian duets, so tliat it is not 
strange that reimiaids of the un- 
ileveloped duets should Ix* fomid 
in the adult. The steps of the 
ilevelopment of tlie sexual organs 
are mdieated in Fig, 71, page 198 
and in Figs. 1;>S-162. 

True HemmpkroditimL — A true 
herma[>hrodite, according to 
Neugebauer, is an individual who 
ean impregnate another and also 
ean be inipregnated it.^*If by 
another individual ; not only that, 
it niay impn*gnate itself. Areord- 
ing to this definition true hermaphroditism occurs in the lower 
animals, as in the eestoiKMls. Tlie gastrojjods, on the other hand, 
can fructify each other but not themselves. True hermaphrmlitism 
in the functional sense does not occiu* in man. but in the sense that 
an indi\idual may have a genital gland which contains both 
ovarian and toticular tissue, an ovotestis, five undoubted! cases 
liave bc^sen rej>orted, by V. Sal^n, Garr^, Pick, and Schickele. One 
of Pick's tw^o cases was that of a woman who had borne several 
chiltlren ami Garre's case was that of a male hermaphrodite twenty 
years old. Tiierefore, true liermaphrtxlitLsm, defintHl as the occur- 
rence of a combination gland of both ovary and testicle in the vsame 
person, does occur. A iireponderating number of the n*pfjrted 
cases are instances of pseudohermaphroditisuL Neugelriauer in his 
exhaustive work has gathered together 1^886 cases of pseudoher- 
maphroditism m aildition to the five cases of true hermaphroditism. 



Fig. 173. — Hematocolpos, Homato- 
metra and llematoBalpiax. 




400 DISEASES OF THE VULVA 

Pseudoherniaphrodiiisrn. — Pseudohermaphroditism is more often 
of the male variety. 

Male False Hermaphroditism. — Here the body form, statm^, 
hair, and breasts are of the male type; testicles are always present, 
but the external genital organs are malformed. The penis is un- 
dersized and the glans imperforate, while the penile urethra is 
represented by a groove running into a cul-de-sac which corre- 
sponds to an incomplete vulva. The two halves of the scrotum 
have failed to imite in the median line, thus resembling the labia 
majora, and enclose a rudimentary vulvar orifice scarcely admit- 
ting a finger tip. One half of the scrotum may contain a testis, and 
the other testicle may be in the inguinal canal. It is a condition of 
hypospadias in the male. There are many varieties of this type. 
The cases are apt to be regarded as females and are brought up as 
girls imtil after puberty when they show sexual inclination toward 
females. 

Female False Hermaphroditism. — ^This is less common than the 
male kind. The ovaries are always present, but may be in the 
labia majora. The boily form, stature, and hair are of the female 
type, but the individual may have a beard and the breasts may be 
poorly developed. The clitoris is large, resembling a penis, the 
labia majora are fused in the median line so that they are like a 
scrotum, and the vagina is small. 

For a complete exposition of this subject, with descriptions and 
illustrations of the many cases of hermaphroditism that have been 
reported, the reader is referred to Neugebauer's work ("Her- 
maphroditismus beim Menschen," 1908). 

INJURIES OF THE VULVA 

Injuries of the vulva may be divided into (a) those due to child- 
bearing, (6) those due to direct violence, and (c) those due to 
coitus. 

(a) Childbearing. — ^Thc labia majora are apt to be bruised and 
lacerated, more often the former, by the obstetric forceps. Lacera- 
tions are generally sup(»rficial, l)ut may involve the vulvo- vaginal 
glands. Hematoma of tJw labium mxijus occurs occasionally follow- 
ing difficult labor and may attain great size. It is especially liable 
to occur in patients who have suffered with varix of the vulva 



INJIUIIES OF THE VULVA 



401 



during late pregnancy. Hematoma ih diagnosofl by a tense sfweliing 
of a dark eoior, due to the clotte<l blooii showing through the skin 
of the labium^ and it is very sent^itivc on pressure, Sueh a lienia- 
toma verj^ seriou.sIy eoniplieates labor. The nynifihte are torn now 
and then, but nuch woonxls are s^'kiom serious. The veMilutleinay 
1m^ torn near the clitoris so that dangerous hemorrhage may result, 
but this is an imusual occuiTence. Injuries of the hymen have 
lxH:*n referred to under the malfomiations of the hymen, page 
396, and lacerations of the pcTineum arc treated oi the chapter on 
diseases of the vagina, page 372. 

(6) Direct Violence. — The \ailva, Ix^aiisc* of its situation, Ls pn>- 
tected from the ojore coirirrion forms of injurj'. I^ut may bt^ injured 
by falls Bestride of a sharj) object, or by kicks, or blows. The close 
j>roximity of the unyielding lx)ny arch of the pulj<^s and the abun- 
dant bloo<i supply of the parts make wouiids in this region more 
serious. Women have fallen astride of a chair, or a pitchfork, or 
the saddle of a bicycle, or a fence picket, with resulting wound of 
the vulva, generally attendeil by excessive bleetUng. Blows or 
kicks are apt to take effect on the labia majora with resulting 
fwmalomaj generally of one labium, and sometimes of considerable 
size. The hematoma may supinirate, become gangrenous, or, if not 
of a severe grade, may Ix^ absorbed. The dark blotxl generally 
shows through the skin ; the hematoma is not often larger than a 
closed fist, and of course is very sensitive. Children have Ix^en 
injured by stilinters of wood penetrating the vulva while sliding 
down a Ix>ard, or by bi4ng tlu*own on sharp objects while 
coasting. 

(c) Coitus* — Injury of the hymen at the first intercourse often 
results in bleeding which ha^ Imm known to be alarming in amount 
in very rare ease«; usually the bleeding is of no moment. Severe 
injury of the vulva from rape upon young girls has been reported, 
the wound involving the fK^rineum, labia, or even the rr^cto-vagmal 
septum, there being cases on recoril where a recto-vagina! fistula 
resultexi from brutal coitus. Dispro|>ortion in the size of the penis 
and the vagina in the ease of young girls and ol*i women has given 
rise to injmies, wliich niiLst Ix; considered as of infrequent occur- 
rence. 




402 DISEASES OF THE VULVA 



INFLAMMATION OF THE VULVA: VULVITIS 

The vulva, being covered by modified skin and hair, is affected 
by the same sort of skin diseases as the other hairy parts of 
the body. The forms of skin diseases that most frequently affect 
the vulva are, erythema, eczema, herpes, acne, tuberculosis, con- 
dylomata, kraurosis, elephantiasis, thrush, pediculus pubis, syph- 
ilis, erysipelas, diphtheria, and gonorrhea. The last is the most 
frequent of the causes of inflammation of the vulva; other causes 
are, lack of cleanliness, irritating vaginal discharges, or irritating 
urine, as in diabetes mellitus, local irritation, as from scratching 
or an ill-fitting napkin, and, finally, any constitutional exhausting 
diseases that lessen the resisting power of the tissues. 

Simple or Catarrhal Vulvitis. — Simple or catarrhal vulvitis is the 
most common form of vulvitis and may be due to want of cleanliness, 
pediculi pubis, excessive coitus, abnormal discharges from the uterus, 
fecal or urinary fistulse, or malignant disease. In the acute form 
it is characterized by tenderness, burning and throbbmg at the 
vulva, smarting on urination, and profuse, non-purulent discharge. 
In the chronic form itching and burning are noticeable S3rmptoms, 
also a discharge that is thinner and less in quantity than in the 
acute stage of the disease. The vulva is congested and more or 
less swollen in its various parts and there may be excoriations or 
even ulcerations. In some cases the hair and sweat follicles are 
infected and the vulva is studded with papules and pustules. This 
follicular vulvitis is a rare form of vulvar inflammation seen mostly 
in the clinics of Europe. In diphtheritic vulvitis a characteristic 
gray membrane, composed of fibrin, is formed on the vulva, and a 
similar appearing membrane, but with little fibrin, also occurs in 
I)U(»rperal cases from the action of bacteria other than the Klebs- 
L()(»fHer bacillus, generally the streptococcus. The superficial 
inguinal glands take up infective matter from the vulva and even 
in the simple, catarrhal vulvitis may be enlarged. The disease has 
no tendency to invade thc^ vagina or urethra and microscopic ex- 
amination shows the absence of the gonococcus. 

Gonorrheal Vulvitis. — In this variety, by all odds the most fre- 
quent form of \ailvar inflainination, the disease has a tendency to 
invade the neighboring organs, and we have vaginitis, endocervi- 



mPL/VMMATION OF THE VULVA 



403 



» 



citfe, urethritis, anil inflammation of Skene's and Bartliolin's glands, 
as well as the vuhitis proper; the \iilviti.s, in fact, being the least 
important of the gonorrheal prwesses. The discharge is purulent 
antl of a yellow or greenish-yellow color; the disease alTocting tlie 
urethra early, there is burning, and frequent micturition frorn the 
beginning. The inguinal glands may be involved and a **bubo'' 
is developed in the course of a few days; also, the -^ndvo-vagioal 
glands are apt to be* infected. The diagnosis rest^ on the severity 
of the inflammation following a suspicious intercourse, on the 
[jresence of urinary sj^mptoms, on being able to expre^ss a drop of 
pus from the urethra or one of Bartholin's glands, and on finding 
the gonoeoecus in the cliscliarge. Gonorrheal \^lvitis is not un- 
common among infants and little girls, especially in institutions, 
and may lead to adhesions of the labia minora or even the labia 
majora. The entire vulvar cleft may Ix' closed except a small open- 
mg either in front or Ix^hind through which the lu-ine escapes. 
Lesser degrees of adhesions are by no mc^ms rare, and careful ex- 
aminations of the women who present themselvc^s in the out-patient 
clinics will reveal many causes of agglutination of portions of the 
nyniphff , or adhesions burying the glans clitoridis. 

Diabetic Vulvitis. — Diabetic vulvitis is an ujflammation of the 
^'iilva caused by the decomposition of the urine iudialx»tcs mellitus 
by the saccharomyces fungus. Its symi>toms are burning and 
intense itching, and tenderness of the \Tilva. On uispeetion the 
vulva is of a dull, n^ldish color and the surfaces of the labia an* I 
vestibule are parchment-like, corrugated, and dry. Excoriations 
from seratcliing are to be expecte^l, or even the presence of small 
lx>ils, and in time the disease affects the skin of the mons veneris 
and the insides of the thighs and the anal region. The* diagnosis is 
made by finding sugar in the urine and by the ap{xarance of the 
vulva, which is most characteristic. 

Thrush of the Vulva.^ — This rare disease is caused by the Saechar- 
om3'<;e.s aibicuiks, just as in the case of {mrasitic stomatitis. It is 
found most often in nursing women, in advanced dial>etc*s, tub<T- 
culasis, cancer and in women who are exhauste^l physically. The 
parts affeeted are covered with slightly elevated, snow-white siK)ts, 
which have a tendt^ncy to coalesce ami leave shaUow ulcers. The 
fiaecharomyces fungus in the form of mycelium and six)res may be 
found in the discharges scraped from the sui'face. 




404 D1SE.\SES OF THE VULVA 

Elephantiasis of the Vulva. — Elephantiasis is extremely rare ex- 
cept in tropical climates. It affects mostly the labia majora, but 
may involve the clitoris or the nympha}. It occurs between the 
twenty-fifth and fiftieth years of life, and is characterized by 
thickening and enlargement of the tissues, sometimes forming a 
large tumor that has fissures and ulcerations on its surface. 

Pruritus Vulvae. — ^This is a symptom which may be due to a 
variety of causes, and consists of intense itching of the vulva. (Sec 
also Chapter X., page 160.) The various skin diseases such as eczema 
and pediculosis are characterized by itching, also the vulvitis due 
to diabetes, and the presence of Ascaris lumbricoides and Oxyuris 
vennicularis, especially in young subjects. Lack of cleanliness 
may cause itching and so may irritating discharges, as well as con- 
gestion of the vulva, as in varicose veins of the vulva and in preg- 
nancy. Aside from these definite causes the terminal nerve fila- 
ments in the vulva may be affected so that itching results, as in 
the case of some old women and in certain nervous diseases, and 
we arc ignorant of the causation. For the purposes of prognosis 
and treatment it is important to determine, as far as possible, a 
definite cause. Great sensitiveness of the vulva may be due to a 
neuritis affecting the nerves of this region, and the physician wll 
do well to rule out this affection before resorting to local treat- 
ment. 

Kraurosis Vulvae. — Kraurosis vulva? is a progressive atrophy 
and contraction of the tissues of the vulva of unknown cause, 
occurring mostly after the age of forty. The disease affects the 
nympha^ clitoris, and vestibule and begins as small brown spot^, 
of irregular shape and slightly depressed, on the surface of the labia 
minora and the vestibule. Soon the tissues of the vulva become 
tense, shining, white, and contracted; the meatus urinarius pnv 
sents a reddened promhient appearance, and along the caruncuhe 
myrtiformes arc small patches of subcutaneous hemorrhage. The 
nymphui atrophy. The orifice of the vagina becomes contracted 
so that it will barely admit the tip of a finger without causing 
hemorrhage or great pain. The pubic hair has a peculiar stubbly 
appearance and may be brokc^n or may come out. The labia majora 
are not much affected by th(» atrophic process, as a rule. Micro- 
scopic examination of the tissues shows small-round-celled infil- 
tration and great development of fibrous tissue, with absence of 



INFLAMMATION OF THF niLVA 



405 



hair fullick'S atiil i^t'lmeeous glamls. 1x11 to iisvU the disoaso nins 
a i'lironic courj^e uf five or six years. The sj^mptoms arc great 
irritatiuri» srnaitiiig on urination, and i)ainful intercourse, wliich 
may cause laeeratJons^ the parts iK^ng very friatjie; the lacerations 
Ix'ing severe if pregnancy and klx>r occur. The symptoms may be 
entirely relieved when the atrophic process has readied its 
ehmax. The chagnosis is established by the ajjpearaiiee of the 
vulva. 

Edema and Gangrene of the Vulva. — Edeina of tlje vulva may 
oct*ur as a result of vnhitis, Imt is more commonly tlie result of 
interference with the jielvie circulation by pressure on the [x^lvic 
veins by tumors, pelvic iiiflaTrmiatory masses, or the iiregnant 
uterus, or it may form a part of a general anasarca. The nyrnphu^ 
and the prr^puce of tlie clitoris are the parts mostly affectnl^ l>ut in 
extreme cases the labia majora and even tlie nions veneris become 
enonnously distended. Pitting of the tissues on pressure is the 
diagnostic sign to bi* looked ior. Giingrene may follow^ excessive 
edema or erysi|)elas of the vulva, eras a complication of the exan- 
themata, also in dirty, undei^(*d children, where it is analogous to 
noma, or as an epidemic puerperal disease, or an ^cute inflammation 
indr'pendent of contagion. The nyni))hae are the portions of the 
\ulva most affected by gangrc»n(\ It In'gins usually as a livid retl, 
indurated swelling of one laliiym, soon breaking down into dirty 
gray or dull red ulcerations anil followeil by a gret*nish-blaek layer 
of gangrene, 

Varix or Varicose Veins of the VuJva. — Varix is found often < luring 
the later months of prc*gnancy. The enlarged veins are in the 
labia majora, and one or lx>th sides may bc^ involved, the left 
mon* often than the right. The vulva Ix-ing well supplied with 
bhxxl-vessi»ls and also with erectile tissue, it is not siu-prlsing tliat 
obstruction to the veins should result in varix. The dark veins may 
Ik* S4*en through the skin of the laljiuni, an<l to the toucli [iresent 
the ehai^aeteristie feeling of a bag of worms, as in the case of vari- 
cocele of the scrotum. Simitar varicosities are to be found in the 
veins of the ujiper and iimer thigh ^ and also in the vagina. 

Rupture of the vtMus of the vulva during delivery results in a 
hematoma of the vulva. 




406 DISEASES OF THE VULVA 



VENEREAL LESIONS OF THE VULVA 

Venerear lesions include chancroids, chancre, mucous patches, 
and condylomata lata and acmninata. 

Chancroids are most often found on the fourchette, the inner 
surfaces of the labia majora, the nymphae, and the vestibule; they 
are multiple as a rule, and are more common among the uncleanly. 
Secondary infection is usual and fresh chancroids keep appearing; 
and often some that seem to be healed break down and ulcerate 
anew. The lesion begins as a pustule that soon becomes an ulcera- 
tion; the ulceration has a punched-out undermined edge, a 
soft, non-indurated base, which has a granular, uneven surface 
covered by a purulent discharge. This discharge is auto-inoculable. 
The sore is sensitive to touch. The chancroid appears about forty- 
eight hours after an infecting coitus and develops rapidly. Second- 
ary infection of the lymphatic glands of the groin (a bubo) 
involves commonly only one gland in a severe grade of inflanmia- 
tion, causing pain, and often suppuration. 

Chancre of the Vulva. — ^This is relatively rare, an extrargenital 
situation of the initial lesion of syphilis being more frequent in the 
female than in the male. Also, because of the inaccessibility of 
the parts and the trifling discomfort to which they conmionly 
give rise, chancres of the vulva often escape observation. The 
initial lesion of syphilis, if situated on the vulva, is generally to be 
found on the labium majus; the next most frequent situation.is the 
fourchette, then the nymphae, the clitoris, and the mons veneris in 
order of frequency. The chancre appears as a hard, red lump which 
soon ulcerates; the induration of its base being a characteristic 
feature, also the enlargement, in six to ten days after its appearance, 
of the individual lymphatic glands in most intimate connection with 
it. The chancre appears after an average period of twenty-six days 
from the time of moculation, and is nearly always single, but may 
be multiple if several abrasions have been inoculated at the same 
time. The ulcer formed by the chancre has smooth edges, often 
elevated or slopmg, never undermined, and the base is of smooth 
surface and mdurated, and the secretion, which is serous and 
scanty, is not auto-inoculable. The infection of the lymphatic 



VEKKREAL LE8I0NS OF THE VULVA 



407 



glands of the groins, primary atlenopathy, affects several glands in 

a painless eidargement. 

Diagno.vs of Chancre of ihe Vulva. — The diagnosis of chanere is 
often a matter of extreme (Uflieulty. The diseovery of the Spiro- 
cha?ta pallida in the secretions or a smear from the chancre makers 
the iliagnosis sure, i^iit failing this the tlireo most important points 
are, the long {x^riod of incubation of the cUsease^ the induration of 
the* Imse of tite sure, and the erdargeinent of the individual lym- 
phatic glands in the groin. 

A rwent writer on the diagnostic significance of the spiroeluTta 
palhda, R. P. Campbell, Jouk American Medicat Association^ Vol. 
LIV, Mareli 19, 1910, page 924), speaks as follows from a large 
clinical expcTicnce in Montreal: "It should be possible to fuid the 
spiroehreta pallida in afjproximately IfX) per cent of chancn^s ex- 
cluding those wliich are nearly Jit^aied, or have brn actively treatiMl, 
and some cases of niixinl infection. In vie>w of this fact, treatment 
should not he Ix'gim Ixvfore the diagnosis is confirmed by finding 
the spiroc'ha^te/* 

Differential Diugno/ns. — Herpes of the indva is exelmled by the 
ai»ix*arance and the fc'<'l of the lurpc^s: a superficial grou|> of 
vesicles with a soft base disajipearing after a short tinu*. The 
crojis of her|x^s may b<* nmltiple, while chancTe is sin^l<\ 

Furuncidosiji of the vulva has bt^en mtsiakeo for chancre, lli^rt^ 
the boils are apt to Ix* multiple and run the usual coui-se of a 
furuncle. The chief lesion that is coiifouiided with chancre is the 
chancroid, and the distinguishing characteristics of the two lesions 
have been touchetl y|)on in the tw^o preceding pages. 

Mucous Patches.— Mucous [matches in the \Tilva are a fretjUrnt 
manifestation of secondary syphilis. They occur as moist. |)a|>ular 
syphilides anil erosions, and have a dist^harge w*ith a foul fnlor. 
The Spirochtcta pallida is abimtlant in scra|>ings from these patrhr^s 
and they are a most frequent source of s}T3hilitic contagion. They 
are apt to fx* converted into camlylomata lata or into a fusion of 
8«?veral papules to form cvauliflower-like growihs on the genitals, with 
fissures and ulciTations. Condylomaia acciiminata, occiUTing in 
casej^ of gonorrhea and unclean persons with irritating vaginal 
discharge, are not the same as the condylomata lata. The acum- 
inate variety are pointetl, more w^art^like, |x^limculated, and of a 
branched, tn^^like character. Their color may Ix? that of the sur- 




408 DISEASES OF THE VULVA 

rounding skin, or, if the epithelium has been removed by friction or 
maceration, they are of a deep reil hue. They have a foul discharge 
and may affect any portion of the \^lva or the inner surfaces of the 
thighs, and may grow to the size of a fist. 

Gumma. — ^A gumma as a manifestation of tertiary syphilis may 
develop as a round tumor in the labium majus. It has a tendency 
to break down by a sort of fatty degeneration, but not to suppurate. 



TUBERCULOSIS OF THE VULVA 

This is a rare affection, there being on record only some fifteen or 
twenty cases. The disease is generally seen in the ulcerative 
stage in women between twenty and forty years of age, the ulcers 
being of a grayish color, of varying size, with irregular edges, ex- 
hibiting in their bases tubercles in process of cheesy degeneration, 
and friable, poorly nourished granulations. The ulcers are situ- 
ated in the vestibule or on the labia or perineum. The diagnosis 
is often difficult, nmnerous sections of the ulcerated tissues being 
made before tubercles and the tubercle bacilli are found. The 
inguinal glands are not affected m this disease; the ulceration pro- 
ceeds slowly, having a course of from eight to ten years, and there 
is no marked induration of the tissues. The disease has been called 
also lupus vulvae, and esthiomcnc de la vulve. 



CYSTS OF BARTHOLIN'S GLAND 

It is not surprising that the duct of the vulvo-vaginal gland, 
which is only half a miUimeter in diameter at its exit, should become 
occluded as a result of infective inflammation, thus damming up 
the secretions. Gonorrheal inflammation is supposed to be a 
cause for the obliteration of the duct of the canal and therefore a 
cause of the formation of a cyst. Be that as it may, cysts of Bar- 
tholin's gland are of sufficiently common occurrence. They are 
usually unilateral, vary in size from half a centimeter to four 
centimeters in diameter, and occur during the' childbearing period 
of life. The smalkT ones may be due to the occlusion of a second- 
ary, branching duct, rather than the main duct. 



ABSCESS OF DARTHOLimS GLAND 



409 



A cyst gives little trouble as a rule, though the la^ge^ ones may 
interfere with coitus; they are rarely painful. The patient gen- 
erally gives a history of old iiiHaoitriatinn of the vulva. Tlie 
diagnosis consi^is bi deteeting a Huetiiating, not tender swelUng in 
the situation of the vulvo- vaginal glanti (see figures from Huguier). 

Cysts of the secondary ducts and of the gland itsc4f ai*e situate* 1 



Fio- 174,— €yBt of the Left Bartholin's Gland. (After Huguier,) 

deeper in the tissues and farther from the introitus vaginie than 
cysts of the main duct, and such cysts may be multilocular, wlien^ 

as cysts of the main thiet are always unilocular. ^\Tien laid open 
cysts of Bartholin's gland are fouu<l to Im* filled with a glairy, 
colorless, white-of-egg mucus, and to be lined by a smooth mem- 
brane, 

ABSCESS OF BARTHOLm'S GLAKD 




Abscess of the vulvo-vaginal glands is very common and is due, 
Iji a large proportion of cases, to gonorrhea. One gland at a time 
is affected, as a rule, moi-e oft(*n the left, and the tlisease is generally 




Fig, 175.— Abscess of the Ducts of Botli Bartholin's Glands. (After Huguier,) 

later stages of gonococcus infection. Then there is a recurrence of 
heat and burning in the vulva with sharp pains, slight elevation of 
temperature, an<l tenderness of the tissues, the symptoms lx*ing 
aggravated by staiKiiig, walking, and sitting even, the patient 
being most comfortable in the recumbent postiut*. There may be 
retention of mine, or the urine simply smarts. Examination 
shows swelling and edema of the labium and sometimes pus escapes 




ABSCESS OF BARTHOLIN'S GLAND 



411 



from the orifice of the duct on the inner surface, or the abcess may 
be evacuated spontaneously through o|>enings below the orifice. 
The inguinal IjTiiphatic glands are affected sometimes and a " buto '* 
results. After the subsidence of the acutt; inflammation the vulvo- 
vaginal gland is apt to renmin iu a state of chronic inflanunation 
and a drop of pu3, perhaps with a pjeenish tinge, or a muco-puru- 



» 



Pin. 176, — Ab«*ees8 cif Both Bartholin's (jlands. (AfkT HuguMT/y A DtOp 
of PiiH is shouTi in the Urifice of Each Duct. Noto Rdation of Urifioea to 
Introltujs Vagina. 

lent discharge issues from the duct. At this stage the orifice is 

surroundf*d by a red areola whif h resembles a flea bite, the so-called 
nmcula gonorrhoira of Sanger. It is in this stage that infection is 
apt to be transmitted to the male and light up in his urethra an 
aeote gonorrhea, or it may cause puerjieral sep^sis or ophthalmia 
neonatorum. Relapse Is conunon in abscess of BarthoUn*s gland 




412 DISEASES OF THE VULVA 

and the opposite gland may become infected, therefore prompt 
surgical treatment is indicated. Smears should be made from the 
discharges and exammed for the gonococcus. 



DIFFERENTIAL DIAGNOSIS OF CYSTS AND ABSCESS 

In cases of long-standing mflammation the tissues may be so 
thickened that malignant disease is simulated. Microscopic ex- 
amination of tissue excised will establish the diagnosis. A rectal 
fistula discharging through the labium has been mistaken for an 
abscess of Bartholin's gland. Examination per rectum in such a 
case reveals bra^^^ly swelling, and the opening of the fistula in the 
bowel may be made out by means of the proctoscope and the 
probe. Hematoma of the labium makes a more uniform swelling 
than a cyst or abscess and feels doughy, also the skin is dark in the 
case of the hematoma and there is a history of injury or of recent 
parturition. Inguino-labial hernia appears in the upper part of 
the labium and tends to disappear when the patient lies do\^Ti. 
There is an impulse on coughing, and in the case of hydrocele of 
the canal of Nuck the swelling is also in the upper part of the 
labium, but it is irreducible. Hydrocele of the Canal of Nuck is 
treated in the chapter on the diseases of the uterine ligaments. 
(See Chapter XU., page 213.) 

LABIAL HERNIA 

An inguinal hernia not infrequently finds its way into the labium 
majus and sometimes there is a double hernia of this sort. The 
hernia descends through the inguina canal and follows the course 
of the round ligament into the labium ; this form of hernia being 
analogous to sctrotal hernia in the male. The hernial sac may con- 
tain only OHK^ntum or it may hold intestine, the uterine tubes, the 
ovaries, or even th(^ uterus. It is caused by the failure of the. canal 
of Nuck to become obliterated. The patient complains of pains in 
the re^on of the hernia, especially on exertion, and is apt to suffer 
with dyspepsia and constipation. If the hernia is reducible the 
lump in the vulva disappears when the patient is m the recumbent 
posture. 



BENIGN TUMORS OF THE VULVA 



413 



If tiie sac contains oniciitiini the swelling is irregular in fwl, 
provided the fat over t(i<^ tumor i.s not excessive in amount, thus 
obscuring the tactile sen^i*. Tht- pereussion note is flat and there 
is no gnrglmg sound in it when reduced and very little impulse on 
eoughhig. 

If the henual sac contains intestine the swelling is smooth, regu- 
lar, and elastic. It is increased in size and heenines more tt'iisr on 
coughmg or strainhig, and if rediieible disapix'ars or becomes 
smaller when the patient lies down. As the hernia goes back into 
the alxloniinal cavity a gurgling soimd is heard. The tumor of the 
labium is tynipantic to percussion and an impulse is transmitted 
to it when the patient coughs. 

Shook! an ovary Ix' in the hernial sac pressure will cause puin 
similar to tlie pain experienced when tlM^ nnrmai ovary is pressed 
between the hngers in a bimanual examination. 

If the uterus is in the sac bimanual examination of the pcJvis 
will n^veal tlie al>sence of the uterus from its usual situation. 

Differential Diagnosis. — Hernia into the lal>ium must Im* *hffer- 
entiated from hydrocele of the canal of Nuck, from a tumor of the 
labium, or a cys-t of Bartholin's gland. From the first it is distin- 
guislied by the fact that it is tympanitic, hasan impulse on coughing, 
may have an irregular contour, is reilueibk% and has gurgling on 
re<luction. Hydrocele is irreducible, is of smooth outline^ lias no 
impulse, and is flat to percussion. A solid tumor of tlie labium is 
generally of liard consistency; it projects from the surface, him 
no impulse* on coughing and no gurgling. A cysi^ of Bartholin's 
gland is globular, lias no impulse, Ls flat to percussion, and is situ- 
ateii in the lower part, of the labium, wiien>as a hernia is oval, has 
an impulse, may be tympanitic, and is in the upper part of tlie 
labium. 

BENIGN TUMORS OF THE VULVA 




These are fibroma, myoma, myxoma, neuroma, angioma, lijjonia, 
and cysts. They are rare. Most of them afl'cct the labia majora. 
J. Bondi has found three s<>rts of cysts of the labia minora, of which 
the mucous cysts are the most fre(|iieiit. lie tliitiks tliey re|)resc*nt 
remains of the W'olffian botlies* They are situated in the upper \mn 
of the labium. Lipoma may grow from the fatty tissue of the 



414 DISEASES OF THE VULVA 

mons veneris or the labia majora, or even from the nymphae, and 
may attain considerable size. The diagnosis of benign tmnors 
can not be made exactly, short of removal and microscopic ex- 
amination of the tissues of the tumor. Slow growth is the rule, and 
the only symptoms are interference with coitus and the discomfort 
attending the presence of the growth. 



MALIGNAirr TUMORS OF THE VULVA 

These are cancer and sarcoma. 

Cancer. — Primary cancer of the vulva is rare. It is a disease of 
advanced life, usually occurring between the ages of forty-five and 
sixty. Its most frequent point of origin is the groove between 
the nympha and the labium majus, but it may develop from the 
prepuce of the clitoris or any of the structures of the vulva. The 
cancer appears in one of three forms, as a circumscribed elevation, 
as a deep ulceration with infiltrated margins, or as a diffuse infil- 
tration. The circumscribed growth is a firm tumor rising from 
the surface of the vulva and more or less movable on the under- 
lying, infiltrated tissues. If the cancer has broken down it is a 
friable lobulated or warty mass, showing points of ulceration. The 
surface is granular, furrowed, and bright red in color, and the base 
is indurated. The carcinoma may invade the deeper tissues from 
the beginning, not forming a circumscribed growth on the surface. 
In this case the tissues become of a brawny hardness and are 
thickened over an area of considerable extent. This sort of growth 
may progress very slowly, and ulceration may not appear for 
several years. The tendency of the disease is to involve the struc- 
tures of one side of the vulva and then to extend to the opposite 
side, perhaps by inoculation. The lymphatic glands of the groin 
are involved early, and the individual glands are to be distin- 
guished as separate, hard lumps. 

Cancer of Bartholin's gland occurs as a round, indurated tumor, 
often as large as a hen^s egg, in the lower portion of the labium 
majus. The tumor is generally very vascular, and large vessels 
can be made out in the overlying skin. 

Cancer of the vulva is of the type of squamous-celled carcinoma, 
and cancer "pearls," due to horny degeneration of the centers of 



MALIGNANT TUMORS OF THE VITLVA 



415 



the epithelial nests, are abundant. Like cancer in other situations 
in the genital organt^, this form of cancer has no symptoms which 
are peeuHar to itt^ff* Pain is a late symptom after the disease 
has extended and involved the larger ner\^e trunks. Ulceration 
causes local tenderness and a discharge. 

Dijfermiiial Diagnom of Cancer. — In the early stages of cancer 
the following disea,sps must teexehided: tulx^rculosis, condylomata 
lata and acuminata, chancre, chancroids, and urethral caruncle. 
Tu^MTculosis occurs in younger women, i.e., between twenty and 
forty years of age, and is of slower gro\Yt.h; the nodules are mul- 
tiple and soft, the induration of the base being absc^nt; tulxTcles 
may often lx» seen in the cheesy degenerated areas; and the in- 
guinal glands are not involved. The microscofx? will settle a doubt- 
ful diagnosis. It is to b^ rememl>cred that the two diseases are 
Ijoth present sometimes in the same case. The tu>o sorts of condy- 
lomata are excluded by the history; in the case of condylomata 
lata there is a history of syphilis, and in condylomata acmninata, 
of gonorrhea; also l)y the absence of uJeeration and jjam. 

Chancre in Us early stages may resemble cancer. In the former 
there is a history of infection followed by a definite period of in- 
cubation^ twenty-six days. The initial !(\sion is not painful, its 
ulcer shows no tendency to spread to the surrounding tissues, and 
its discharge is scanty, niuco-purulent, and thin, as opposed to the 
profuse [lurulent discharge of the cancerous ulcer. If the Spiro* 
cha'ta pallida can be ftJimd in smc^ars from the surface the diag- 
nosis of clumcre is made certain. Also, the si*condary symptoms 
of syphilis are dcveiopcd within six weeks after the api>c?arance of 
the initial lesion. 

Chancroids are preceded by a history of infection two clays or so 
Iw'fore the deve!o|)iiient of the ulcers, which are generally multi|>h\ 
Only one lymphatic gland at a time is involved as a rule in chan- 
croitls, and the gland tends to suppurat**; in cancer several glands 
are affected and they do not suppurate. The chancroiil uk^ers are 
puncht^l out, with undennined edges, and their bases arc* of smooth 
surface, and are not indurated. The ulcer from chancre is single, 
it has sloping edges, and a rough and mdurated base. Urethral 
canincie c»ecasionally sinudates Ix^ginning cancer. Caruncle is, 
however, of soft consistency. When ulcerated it should be removed 
promptly and subjected to a microscopic examination. 




416 DISEASES OF THE VULVA 

Sarcoma of the Vulva. — Primary sarcoma of the vulva is ex- 
tremely rare and occurs in young subjects as a rule. The melanotic 
variety is the one most often found, but spindle-celled and round- 
celled forms have been reported. In the melanotic variety the 
lesions are multiple and appear as hard, round nodules several 
centimeters in diameter, df a black or brown color, and originating 
in warts, moles, or nsevi. The nodules tend to coalesce and to 
become ulcerated, but do not attain great size. In the other 
varieties the nodules are generally single, grow rapidly, and may 
attain considerable proportions, even as large as a man's head. 
They do not ulcerate and the lymphatic glands are rarely afifected. 



CILVPTER XXH 

THE DIAGNOSIS OF UTEIUNE IMlIvGNANCY. ABORTION, 
AND HYDATIDIFOllM MOLE 

Diagnosia of ntirnml uterine prcjifnarK-v, ji. H7: During Ihe first Hiree 
iiionlhs. p. 418; Hislary, p. 418, Anienorrhoii, [i, 41 1>, Nausea and vurnit- 
ing, p. 419, Siiljvation and niinor digestive dislurbaiK-eii^ p, 45iO, Breasts, 
p. 4*20, Leucorrhea, \k 440, Bladder disturbautfR. p. 4^0; luspet-tiou and 
palpation, p. 4^, BreajsLs, p. 4^1, Areola, p. 4^1, Insju^tlion of the vidva and 
vagiiiiit p. 4^1, Bimanual touch, p. 42^1, Dtiring the la.st six uionths, p. 
4'2ti; Jlistory, p, 43 tJ, Quickening, p. 43ti; IrisjKxiion and pa I j nation, p. 4^(i, 
Gait. p. 4^0, Figure, p. 4*^(5, Breasts, p. 44<>» Sect>ndarv aretila* p. 4'26, Vulva, p. 
4^7, Bmianual touch, p. Hl\ Irilernal ballot tenient, p. 4^fJ» Abdomen, p. 4si7; 
Ansenltation, p. 4^1), Tabular statement of s>^!JJl!oms and signs of pregnancy 
by monlhs, p. I'iO, Ditferential diagnosis^ of normal pregiuiney, |>. 4*'J1; 
During the Krst three months, [». 4;il, Anteflexion, p. tlJl, Chronic subin- 
volution, p. 431. Fibroid in the anterior wall. p. 431, Hetroflexion, p, 431, 
Extra-uterine pregnancy, p. 431; During t!ie last six months, p. 43^. 

Diagnosis of abnormal ulcriiie pregnancy, p> 432: Diagnosis of retro- 
flexion and incarceration of the pn»gnant uterus, p. 43ii- Diagnosis of 
interstitial |>regnancy and of fjregtuincy in a ntdinienlary horn of a 
bicormite yterys, p, 433. Diagnosi-i that pregnancy hiis txx-urred pr**vionsly, 
p, 433. Diagnosis of multiple pregnancy, p. 434, Diagnosis of pernicious 
vomiting of preguiincy^ p. 434. 

Diagnosis of abortion, p. 43ti: Definitions, p. 43(1. Frequency, p. 437. 
E(i<ilog\', p. 437, Symptoms, p. 438. Dia^osis, p. 43!); Diagnosis of 
threatened ab^irtion, p, 439; Diagncjsis of inevitable abortion, p, 430; 
Diagno.His of abortion jmrt tally or wholly comjileted, p, 44U; Diagnosis 
of misf'arriage, p. 44<>. Differential diagnosis, p. 440, 

Diagnosis of hydatidiform mole, p, 441: Pathology, p* 441. Symptoms, 
p. 443. Diagnosis, p. 443. 



THE DIAGNOSIS OF NORMAL UTERINE PREGNANCY 

The diagnosii^ of nonnal uterine preguaoey offers often many 
(iiffifulties to the praetising physician antl Is perhaps the most 
imjiortant tlepartnieiit of diagnosis. VanchT Veer collected seventy- 
8even instances of alxiomiital operation.s on :?upp(js4.*dly pathological 
growths, some of tlie o|RTators Ix'iiig men of note, where the pa- 
tient was pregnant in each instance. Hirst mentions the fact 
27 417 




418 NORMAL UTERINE PREGNANCY 

that a gjmccologist on the staff of a large hospital has twice oper- 
ated for fibroid tumors of the womb, and only after the amputation 
of the uterus found that it was pregnant, and not the seat of a 
fibroid tumor at all. Both patients died. I have seen the same 
thing happen in the experience of a prominent surgeon to one of 
the largest hospitals, although the subsequent fate of the patient 
was unknown. I have also known of a surgeon of large experience 
operating for ovarian tumor on the wife of a noted obstetrician, 
the diagnosis being made by the apprehensive husband and by an 
internist, the operation proving that there was no ovarian tumor, 
the excessive abdominal enlargement being due to pregnancy and 
hydramnios. Mistakes are so frequent that no excuse is necessary 
for occupying space in describing a subject which, by a strict in- 
terpretation, belongs in the domain of obstetrics. 

The diagnosis of pregnancy depends on the history; on inspection 
of the face, neck, figure, breasts, abdomen, and vagina; on the bi- 
manual examination, and, in the later months, on auscultation of 
the abdomen. 

During the First Three Months of Pregnancy 

The diagnosis of pregnancy before the fetal heart sounds arc 
heard or fetal movements felt in the fifth or sixth month is not an 
absolute certainty; still, the strongest sort of a probability may 
be expressed if all the facts are taken into consideration. The 
demonstration of the changes in the genital organs due to the in- 
creased blood supply and the growth of the ovum form the basis of 
a diagnosis; contributory facts are the alterations in the breasts, 
the body form and carriage, and the effects on the nervous system. 

History 

To get the history of pregnancy is not always an easy matter, 
for patients not infrequently conceal the facts either because, in 
the case of the unmarried, they hope the physician may pass a 
sound into the uterus and cause abortion, or they are ashamed to 
acknowledge immorality, or, in the case of those pregnant for the 
first time, because of inaccurate observation. Patients who have 
been pregnant previously can say sometimes that pregnancy began 
with a particular coitus when especially pleasurable sensations 



FIRST THREE MONTHS OF PREGNANCY 



419 



were cxperieneecl, also morbid cravings for spwial sorts of food or 
disturbances of digoblion have been the same as with former preg- 
naoei<'s. 

Amenorrhea* — Ateence of menstruation is one of the chief syni(>- 
toms of pregnancy. In quetrtioning the patient the exact date of 
the bi*ginning of the last, menstruation should lx> obtained and aim 
how long it lasted, and wht^ther it was in all respects similar to the 
usual menstroal perioils. Did coitus occur soon after this jierioil? 
The end of the last catanienia is the date from which the Ix^ginning 
of |>n'gnaney is usually reckonetl. If the j>atient has lx*en always 
regutar in her menstruation, amenorrhea of two months is a most 
suspicious circumstance; if, on the other hand, she has \mn 
habitually irregular or if she is nursing a baby, so nmch imix>rtance 
can not be attachefl to it. Cases are on record where menstruation 
has oecurretl at irregular intervals during the entire pregnancy; 
ill fact, one or two shows of blood during the first few months are 
l>y no means uneonunon. Alx)ut half of all nursing women men* 
struate during lactation, and as the number of pregnancies in- 
creiise the tendency to menstruate while nursing increases also, 
therefore amenorrhea durmg lactation is not a constant sign. 
Baudelocque, Deventer, and others have rc^ported instances of 
r«:^gular menstruation occurring only during gestation. I:>ut such 
cases arc rare. Amenorrhea may occur iu chlorosis, inaklcvelop- 
inent of the uterus, or the Ix'giiming of the menopause, in tulxT- 
culosis, oljesity, acute constitutional disc^ases, prolonged lactation, 
clironic poisonings, particularly lead, or frcnu change of climat'C, 
or profound mental disturbance. Amenorrhea is common in girls 
who have immigrated from a foreign country. A majority of the* 
Irish girls seen in the out-| patient clinics of Boston have amen- 
orrhea for several months after arriving in this country. Acro- 
megaly, occurring as it g<'nerally dot^s in young subjects, is apt to 
have complete amenorrhea as one of its first symptoms, and tu- 
Tuors of the bas<' of the brain, esi>i*cially those involving the hy- 
|X)ph>*sis cerebri, as iK>intc*tl out by Harvey Gushing, have amen- 
orrhea 4is a prominent symptom. 

Nausea and Vomiting.~The morning sickness of pregnancy is a 
fairly common but liy no means an invariable accompaniment of 
gestation. It varies from an occasional qualm to active nausea 
anil vomiting occurring when first assuming the erect posture in 



420 NORMAL UTERINE PREGNANCY 

the morning. Some patients can not brush their teeth without 
being nauseated. The symptom does not manifest itself as a rule 
until the fourth or fifth week, but may begin as soon as ten days 
after conception. It occurs also in Bright's disease, gastritis, and 
chlorosis. These diseases must be ruled out, and if there has been 
a previous pregnancy, nausea and vomiting will probably have 
occurred with it. The symptom must be regarded as due to the 
enlargement and stretching of the uterine muscle fibers and nerves. 
The nausea may occur at other times than in the morning and may 
persist throughout pregnancy, although it generally ceases after 
the third month. 

Salivation and Minor Digestive Disturbances. — An excessive flow 
of saliva, heartburn, eructations, and abnormalities in appetite 
such as longings for strange or unusual articles of food, are not 
unusual accompaniments of pregnancy. Occasionally patients are 
seen who enjoy better digestion and even better general health 
while they are pregnant than at any other time. 

The Breasts. — A sensation of weight and fullness in the breasts, 
often accompanied by tingling sensations, is common to pregnancy, 
and patients who are observant note greater prominence of the 
nipples, and enlargement of the follicles in the darkened areolae. 

Leucorrhea. — There is a marked increase in vaginal discharge 
during pregnancy. This is noted early with the occurrence of the 
engorgement of the genitals; but, of course, leucorrhea may be due 
to other causes. It is seldom that the increase in the discharge in 
early pregnancy is enough to attract the patient's attention. 

Bladder Disturbances. — Increased frequency of micturition is a 
most common accompaniment of early pregnancy, probably due to 
congestion of the vesical trigone coincident with the physiological 
hyperemia of the uterine organs. 

Inspection and PcdpcUion 

Since the days of Hippocrates and Democritus certain changes 
in the face and neck have been observed in pregnant women. The 
eyes seem to be deeper set, and may have bluish circles under 
them; there are brownish-yellow blotches upon the skin of the 
cheeks, which are fuller than usual, and the neck seems larger than 
when the woman is not pregnant. Too much importance is not to 



FIRST THREE MONTHS OF PREGNANCY 



421 



be attachetl to these signs^ which nia)' In* tiiitirttly alist-nt. Still, 
one or more of the changes will be found not infrequently if oppor- 
tunity is aflfonlcd for careful observation of the patient both bt^fore 
and durinf^ pregnancy. 

The Breasts. — Enlargerneni. — The l)reast cnLargenient of i>rrg' 
nancy presents a firm, irregular feeling on palpation, and not the 
smooth, Hoft swelling due to inerea^o of fatty tissue* The hanl, 
knotty sensation is due to the increase in the size and nunilxT of 
the lobules of the mammary gland. In the early months this ehange 
is to be distinguished most clearly at the outer eiiges of the gland. 

The. vehhs of the entire breast are enlarged, forming a likie tra- 
ctiy untler the skin, most marked in the neighl>orhood of or in the 
areola. They show better in persons with white, thin skin8. 

The Areola, — The circular area upon which the nipple stands in the 
non-pregnant woman, of a pinkish or somewhat i)igmentetl eolor 
according to the tyjx* of the individual, tlarker in brimettes and 
lighter in bloniles, under the mfluence of gestation becomes darker 
in color. Even in the light blonde the customary i>ink color is 
dcH?pened; in the brmiette the areola becomes the color of the skin 
of a quailroon. In fair women the areola may be elevated above 
the surrounding skin; this feature is brought into iiromine^nce by 
stretching the skin of the rest of the breast. When stinmlateil by 
a touch of the finger tip the surface of the areola will wrinkle up or 
pucker. The ^Tinkling brings into |)rominence the enlarged se- 
baceous follicles, some twelve to twenty in nunlIxT, which project 
about a si.Ktei*nth of an inch aljove the surface of the areola. 

The value of the niamniary signs is greater in first pregnancies 
because many of the characteristics, such sus enlargement and the 
aptx-arances of the areola, persist after the termination of the 
first pregnancy. One must rule out pre\iously existing uterine or 
ovarian disorders, or masturbation, because in these conditions 
the bn*ast. appearances are often the same as in pregnancy. The 
mammary signs are among the earliest of the inilications of preg- 
nancy and are especially valuable as indicative of the probable 
condition in the case of the unmarried where it is necessary for 
the physician to proecxnl with caution. A physical examination of 
the chest gives opportunity to insi)ect the brea^ts, anil their showing 
sometimes warrants further investigation. 

Inspection of the Vulva and Vagina. — ^On separating the labia the 




422 



NORMAL UTERINE PREGNANCY 



vagina will be foimd to be abnormally moist and eovored with 
whitish i^hrcds of desqiianiated epithelium, and the anterior vag- 
inal wall just under the urethra .shows a dusky, purplish discolora- 
tion sonietinu^s called Jaequemin^s si^ iM^auso first noted by this 
author in 1S;37. The discoloration is to Ix* seen first in the b<jttonis 
of the fiUTows of the mucous membrane, therefore it is well to put 
thi* anterior vaginal wall on t lie stretch. This sign may be apparent 
as early ns the end of the first month and is present m over half of 



'''^^^K 



Soft 



Fill, 177. — Diagmmmatic Side View of the Pregnant Utenis of the Sixth Week^l 
during Relaxation. (After Dickinson.) 



all eases by the end of the third month. It is more dii^tinct in mul- 
tipara^ and is more apt to Ix* absent in ])rimi|mne, 

»S|X'eylnm examination of the npper vagina shows the eerv^ix to 
Ix^ of a jnn*plish eolor, soft to tlie feel, and in primipane the oa 
tincsD bc!eomes rounder. Erosions are of a dee[>er purple eolor tlmn 
the surrounding tissues. Many obser\a^rs consider the discoloration 
of the cervix mi earlier and more constant sign than Jaequemin's 
sign. As cong(*stion of vagina and ctTvix may Ix- found in jx^lvic 
disease, such as large ovarian and uterine tumors obstnieting th6 
venous circulation, and in certain constitutional diseases, as heart 



I 




FIRST THREE MONTHS OF PREGNANCY 



423 



disease and cirrhosis, tlie lihysician niUi>l be on his guard. The 
typical discoloration of pregnancy is, however, limited to the lower 
anterior vaginal wall^ about the lower uretlira, and to the ccr\ix; 
whereas in pelvic disease and const itutional disorders the con- 
gi%^tion is general. 

The Bimanual Touch. — ^This is pmetistnl with the patient in the 
ciLstoinary dorsjil position (see jmge 33). The fing*T nrjtes a soft 
cervix. It is to Ix.^ reuienilxvred that softening of the cervix is 



All 
Hard 



Fin. 177/r, — The flame, during Con tractioa* 

found also in septic conditions of the uterus, as in septic endome- 
tritis, so that a soft cervix is not pathognomonic of pregnancy. 
The uterus itself is a little lower in the pc*lvis than nornm!, and is 
enlarged by the growing oMim, which is usually attached to the 
endometriuoi in the neighborhood of the orifices of the tubt»s. The 
uteriLs grows faster than the ovum at first, and the ovum with 
lis envelopes does not fill the uterine cavity until the end of the 
third month, when the tU'cidua reflexa joins the deeidua vera. 

The first change in shajx* notc»il in the gravid uterus consists in 
a sHght enlargement of its transverse diameter; then it Ix^comes 
lengthencHl antl fatter as the ovum increases in she, espcH?ially in 




424 



NORMAL UTEHINE PRBGNANCy 



the anterior part of the tody of the utenis; this anterior bulging 
being quite characteristic in many cases. Asymmetry is caused 
by the de^^elopmeIlt of the o\'aiin in one cornu, a not uncommon 
happening- Uterine enlargement may be deteetnl by the practisetl 
hand as early as the sixth week ; in the third month there can te 
no doubt al>oiit it, even to the tyro. The softening of the uterus 
vari<*s in (hfrerent individuals and at difTereiit tinu^s in the same 
individual. It h less in primipara? than in multipara*, but luider 



^^«awf 



u& 



,oj: 



Fro. 178, — Six-weekn' Pref^not TTtrnis with Elnntpifion of Cemx, Showing 
Extent to which ite Cavity Im (>et!ij|ikHl by tiio Ovum. O.E,, external os; O./,, 
internal os; DA',, decicJua vera; D.S., deciUua serutina; DJi., decidaa reflexa; 
Efnb.f embrj'o; P., placenta. (WUliams.) 

the influenee of jire^aney there is always an increase in ela^tieity of 
the organ. Even as early as the thst weeks the rhythmical cuntrac- 
tions which go on throughout pregnancy may be felt by patient 
bimajiual palpation. They invo]%^e the entire uterus and are ex- 
cited by any manipulation of the organ^ therefore? the bimanual 
examination sliould last from five to ten minutes so that sufficient 
time may be afforded for contractions to take place. Ellice Mo- 
Donald {Amer, Jour. Obsld. , L\1I., 1908) observed intermittent 





FIROT THREE MONTHS OF PREGNANCY 



425 



contmetion.s in S8 out of lUO cases of early pregnancy examined 
with reference to (liagnoHis. Tlie lower uterine sc»gment is the 
I>ortion of the uterus where the softening is most manifest.. The 
softening at this point is called llegar*s sign and can Ix^ determin(Hl 
only (luring uterine relaxation. The upper portion of the uterus, 
l»eing oceupiwi by the ovum, is tense and elastic; below the ovura 
the soft uterine tissues may be eompresse<] Ijetween the finger in 



Fia. 179.— Bimanual Palpation gf Early Pregnancy for Hegar'aSign. (WiUtams.) 

the vagina and the fingers of the ablominal hand brought down 
either in front of the uterus or b-hind it, generally the latt^^n 
(See Fig. 179.) 

Very early in pregnancy palpation with the alxlominal hand in 
front of the twly of the utems and the vaginal finger k^hind the 
cer\ix is somc^times available, especially in cases of retroversion; 
later in pregnancy, when the uterus has become longer and more 



426 NORMAL UTERINE PREGNANCY 

anteflexed, the fingers of the abdominal hand are brought down 
behind the fundus, while the finger in the vagina is placed in front 
of the cervix. The softening of the tissues of the lower uterine 
segment makes this portion of the uterus more flexible than in the 
unimpregnated state. Downward pressure by the abdominal hand 
on the top of the fundus during a period of relaxation, while the 
vaginal finger under the crown of the cervix makes upward pressure, 
causes the uterus to bend in the weakest part, the softened area. 
McDonald found this increased flexibility in ninety-seven out of his 
one hundred cases. 

During the Last Six Months of Pregnancy 
History 

The history is the same, except that nausea and vomiting and 
digestive disturbances cease after the third month, and the bladder 
symptoms are apt to be less. Abdominal enlargement is noticeable 
now, and the patient has to let out her dresses. Quickening, or the 
sensation caused by the fetal movements, is felt from the sixteenth 
to the eighte<»nth week of gestation, some women detecting it 
earlier than others. 

Inspection and Palpation 

The Gait. — In the later months the pregnant woman walks with 
a backward pose, the abdomen, more or less enlarged, being prom- 
inent in front. Ask her to walk up and down the oflice and note 
her gait. Also, the sacro-iliac and pubic joints of the pelvis are 
relaxed during later pregnancy; in women with sacro-iliac disease 
the motion is excessive, and the gait is decidedly wobbly; in other 
women the gait may be little if any affected. 

The Figure. — ^The prominent breasts and protuberant abdomen 
will be noticeable if the physician has been acquainted with his 
patient previous to pregnancy. 

The Breasts. — Besides the changes in the breasts noted as to be 
found during the first three months, there appears at the fifth month 
a secondary areola outside the primary areola which is next to the 
nipple, consisting of a network of pigment around light spots, 
each spot representing a circle round the opening of a sebaceous 
follicle. These light spots may extend all over the breasts, but are 



LAST SIX MONTHS OF PREGNANCY 



427 



moet niarkrtl next to tlir [jriruary angola. Skillful stroking of the 
breast toward the uiiJi»lr will fnree mUmtnim from the nippk? after 
the thirti month. This is a valual*k* sigii of pn^gnaney, although 
milk has {m^n found in the breasts of \^h'gins antl even in young 
ehildriTi of prefocious develofjnient. 

The Vulva.— The vulva, vagina, and cervix have the same ap- 
I>earancu^ as iluring the first tlirei* months, except that the engorgt^ 
menl of thi' tissues is now more iimrkeil. The vaginal discharge is 
increased in amount. 

The bimanual touch detects the ft-tus by inienml balhitemeni 
after the fourth month, for by this time the ciuantity of litjuor 



Flo. 180, — Frimajy and Seooudary Areoke in a Brunette. ("American 
Text-Book of Obstetrics.") 

amnii is sufficient, and the fetus is large enough to permit the 
examiner to feel its bobbing alx)ut in the uterus. Ballottement 
may be praetieed with the |>atient in the dorsal or in the standing 
position, preferably the latter. The |jhysieian introduees one or 
two fingers into the vagina and makes a *iiiick, sharp, upward 
push against the uterus. In a moment the fetus, which Is heavier 
than the Huid in whieh it is suspen<le<l, settles against the examin- 
ing finger with a ttistinet tap. This sign is available during the 
fifth antl sixth months. After that the fetus has grown so large 
that it can not Ix* movetl alxjut frof^y. After the seventh month 
the cervix is very soft and the os is patulous. 

The Abdomen*— PignMiitat ion of the linea alba of tlie ablomen 
is noticeable, especially in brunettei^, after the third month. It 
consists of a dark line alx)ut half an inch mitle extending from the 





Flo, 181, — Enlargement of the Ut<?rus at the Different Weeks of Pregnimcy. 
("American Tex tr Book of Ubste tries/') 

The fimflus uteri is two or tlirec fingers' breadth alx)vc the sjni- 
physis at the end of the fourth month and reaehes the umbilicus 
at tde close of tlie sixth month. 

The parts of the fetuB may be felt in favorable cases by the 
twentieth week (tlie fifth month), k^ing a most valuable sign of 
pregnancy. Excess of lifjuor anmii, a rigid and tliick abdominal 




LAST SIX MONTHS UF PREGNANCY 



429 



wall, or tense uterine walls prevent ihv detection of the fetal parts. 
Fetal movements can be felt by the end of the sixth month witli a 
fair di^griM' of eonfftancy and often nmeh earlier. Placing tht' hand 
ijuietly on tlie abdomen it iii! alloweil to rest there for *sctveral min- 
utes* A very gentle tiirob is felt if in the sixth month, later the 
movements arc stronger. During the sixth month external balloHe- 
jiient may be practised^ a liantl on each f^ide of the abdomen Ix^'mg 
able to push the fetus to anil fro; also intermittent uterine con- 
tractions, r!iythmie antl painless, occurring every five to Urn 
minutes and histing a minute or two, may Ije distinguished l)y 
placing the hand on the alMlomen ami waiting. A sudden motion 
with the hand or a cold hand will often cause a contraction. These 
contractions can be made out thmugh the abdomen after the 
fourth month, but are to be Mi by bimanual touch from the tM^gin- 
ning of pregnancy. A uterus ilistendeil l)y retainetl menstrual 
!)lood or by an intra-uterine tumor has these same rhythmical 
contractions. 

Auscultatimi 

The fetal hmrt sminds are proof positive of pregnancy. Oc5- 
casionally they may be heard toward thi^ end of tiie fourth month, 
but a« a rule are not available as a means of tliagnosis before the 
end of the fifth month. The entire antcTior surface of the uterus 
must be explored with the stethoscope lx^caust» of the varial>le 
jwsition of the fetus, but the most usual situation is Ix^.ween the 
umbilicus and the left ant-erior superior spine of the ilium, IxTause 
the back of the child is situated there in the commonest position, 
left occij)! to-anterior. The heart lx*at has Ix^en likened to the 
ticking of a watch uii<ler a pillow; it is douWe and lias a rate of 
120 to 150 Ix^ats a minute, being increased by the activity of the 
child, by fever of the mother, and at the Ix'gming of a uterine 
contraction, variations of twenty beats a minute l>eing often 
observed in the same fetus. A iderine souffle^ synchronous with the 
mother's pulst* and heard best along the left side of the uterus, 
becomes audible during the f*»urth month antl is a sign of an en- 
larged uterus, but not necessarily of pregnancy because it is heard 
also in large fibroids, 

A summary of the symptoms and signs of pregnancy by months, 
modified from Dickinson, is api>endcd. 




430 



NORMAL UTERINE PREGNANCY 



Summary of Symptoms and Signs of Prkgxancy by Months. 



3s 



2. 



4. 



6. 



8. 
9. 



History. 



Amenorrhea 
throughout 
ail months. 

Nausea. Swell- 
ing and tin- 
gling of 
breasts. 
Frequency 
of micturi- 
tion. 



Ditto. 



Nausea ceases. 



Quickening 



Ditto. 



Ditto. 



Breasts. 



Enlarged 
Veins show. 
Areola pig- 
men ted. 
Follicles. 



Ditto. 



Colostrum. 



Secondary 
areola. 



Ditto. 



Ditto 



Abdomen. 



Pelvis. 



Beginning en- 
largement. 
Pigmenta- 
tion of linea 
alba. 

Fetal heart 
sounds 
heard. Fetal 
parts felt. 
Uterine 
contrac- 
tions felt. 
Uterine 
souf&e. 

Fetal move- 
ments. Ext. 
ballotte- 
ment. Lin- 
ea; albicaL- 
tes. Fundus 
reaches um- 
bilicus. 

Ditto 



Abdomen pro- 
gressively 
larger. 



Leucorrhea. 
Puri>lish 
discolora- 
tion vagina. 
Bulging an- 
terior fim- 
dus. Com- 
pressibility 
of lower seg- 
ment. Soft 
cervix. 

Ditto 



M ISCELULN EOUH 



Cervix softer. 
Fetal Darts 
felt. More 
congestion 
of vagina. 

Internal bal- 
lot tement. 



Swelling of face 
and neck. 

Skin discol- 
orations. 



Ditto 

Cervix high- 
er in the 
pelvis. 



No ballotte- 
ment. 

Cervix very 
soft and os 
patulous. 



Gait unstcmly. 
Backwanl 
poac. Promi- 
nent breasts 
and abdo- 
men. 



Ditto. 



DIFFERENTIAL DIAGNOSIS 



431 



DlFFERENTUL DIAGNOSIS OF NoRMAL PrBX5NANCY 

It has Ix'eii oiy expt^rienco that iii early pn^gnancy a rnalf<»r- 
mation of the uterus or a tumor of the uterus is most often mistaken 
for [»regnant'y» wliereas in the later months an ovarian tumor is 
fre<jyentiy confused with tlie pregnant uteriis. It may Ix^ well to 
mention some of the most conmion mistakci^ in diagnosis, altlifaigh 
there are so many that the adviee a.s to the later months to regard 
all enlargements of tlie aUlomen as due to pregnancy until the 
contrary has been proven, is certainly safe to follow. 

During the First Three Moriths 

Anteflexion with retropositton may elost'ly simulate early pregnancy, 
especially if there is congestion of the cervix and an entlometrial 
discharge. In anteflexion the cervix is not soft, there Is no purfjlish 
ilisc*oloration of the anterior vagina, the eoq^ns uteri is not elastic, 
the lower uterine si^gment is not compressible, there are no rhyth- 
mical contractions, and menstruation still fx^rsists, though irregular. 
.\n exammation st^veral weeks later shows the signs to te the same 
as at the last exaniinatioUj and, additionally, markedly anteflexed 
uteri are generally sterile. 

Chronic subinvolution show^s an enlarged uterus, but the tissues 
are firmer tliau normal, tlte Ixwly is not globular in shape or l»ulging 
anteriorly, and the Iowit uterine st*gment is not comijressible. 
Purplish discoloration is aUsent. Menstruation, though scanty, 
is present. 

Fibroid of the anterior wall is of hard consistency; mensiruation 
is present, iHirjvlish ilisi'oloration is alxsent, rh^ihmical contrac- 
tions may bc^ pn^seiit . Upon a second examination after an interval 
of two wrecks or more, the s<3und may be passed and the situation 
and size of thi* fibroid determined. 

Retroflexion^ — ^The congestcMl fundus may simulate a gravid 
uterus. The uterus sliould be replaced as descrilx^^i in ClMqrter 
XIV.» page 237, and another examination made in the course of a 
few days. 

Extra-uterine pregnancy is considered in Chapter XIX., page 340. 

It is always wise not to hurry in making a diagnosis in doubtful 
cases and ask for another examination, if necessary with an anes- 




432 ABNOmiAL I'TERINE PREGNANCY 

thetic. Nothing is to be lost and often much gained by adopting 
such a course. 

During the Last Six Months 

In the case of enlargements of the abdomen due to other causes 
than pregnancy the rate of enlargement does not coincide witli 
that of the gravid uterus; if amenorrhea is present the duration 
of the absence of the menses does not correspond with the size of 
the tumor, supposing it to be pregnancy; and the distinctive signs 
of pregnancy are absent, namely, the fetal heart sounds, fetal parts 
felt, fetal movements felt, and internal and external ballottement. 
Menstruation usually persists. The differential diagnosis of ova- 
rian cysts, fibroid tumors, phantom tumors, and fat in the abdom- 
inal wall, distended bladder, ascites, tympanites, and the very 
rare hematometra, will be found in the chapter devoted to those 
subjects as shown in the index and need not be repeated here. In 
cases of rigid abdominal walls more than one examination and, 
in very doubtful cases, an anesthetic is indicated. 



THE DIAGNOSIS OF ABNORMAL UTERINE PREGNANCY 

The Diagnosis of Retroflexion and Incarceration of the Pregnant 
Uterus. — ^This not uncommon condition is characterized by a 
tumor of elastic consistency filling the jxihis, the cervix being high 
up behind the arch of the pubes. The symptoms and signs of 
pregnancy are present and in addition there are apt to be pc^lvic 
pains and retention of urine. Before attempting to replace the 
uterus a careful investigation of the urinary function should be 
made and queries asked whether there has been stoppage of urine 
or whether any bits of tissue have been passed with the urine, or 
the patient has suffered with symptoms of cystitis. Krukenberg, 
who with Rivington collected twenty cases of rupture of the 
bladder occurring in cases of incarcerated retroflexed pregnant 
uteri, advises against replacement of the uterus whenever there 
have been passed by the urethra portions of necrotic bladder wall 
because of the danger of rupturing the bladder during replace- 
ment. He prefers to practice abortion. In any event the bladder 
should be thoroughly emptied by catheter before attempts at 



INTEItSTITIAL PREGN.VNCY 



433 



rcplaeiniiont are earriefl out. These arc clone by |»larmg the patient 
in the knee-elu*st position^ making traction on the cervix with a 
t tenaculum and at the same time rocking the funfius upward l)y 
tlie promontory of the sacrum by pressure on the uterus throng!) 
the aUlomen. Often the Sims ix}sition is more favorable for this pr*> 
cedure, and sometimi^s it will Ix* necessary to i)ack the vti^ina with 
cotton tampons and niake a secoml attempt after an interval of 
forty-eight hours. In my experience the adniinisrtratiou of an 
anesthetic is seldom necessary. 

The Diagnosis of Interstitial Pregnancy and of Pregnancy in a 
Rudimentary Horn of a Bicoraute Uterus. — In diapter XIII., page 
198, are de.scribetl the <hfferent sorts of anomalies of the uterus. 
Iv Kehrcr ("Das Nebt*nhom des doi»|H^Iten Uterus/' 1S99) r«>l- 
IccttNl eighty-two causes of |>regnancy in rutUmentary cornua. The 
diagnosis Ixiore ojxTation in a majority of these cases lay between 
extra-uterine |>regnancy, ovarian cyst and subsi^rous myoma. 
The dijignosis of this condition intra vitam mu.st always Ixr 
considered extremely tUfficult. Kehrer cites five physicians witu 
diagnosed the condition correctly and reports the cases in detail. 
The chief jM^int of diffei-ence Ixjtween tuljal pn^gnancy and preg- 
nancy in ihv. rudimentary horn of a uterus bicomis is that in the 
latter there is a thick i>Hliclc or even no pedicle at all l^etwTen the 
uterus and the gi'avid tumor, whereas in extra-uterine pregnancy 
there is a long slim }x\lick% longer in ampullar and istlmiial tubal 
l»r<*gnancy and shurt«*r in interstitial tuijal jiregnancy. 

Inierstitial pregnancy often simulates pregnancy in a rudimentary 
horn. The ovum drveloping in the uterine jiortion of the tulx* causi^s 
asymmetry of the utenis. Only w4icn the conditions for exanuna- 
tion are most favorable can the separation between the pr<^gnant 
hom and the main fundus uteri be felt. The sounti may Ix* passed 
into the main uterine cavity to |>rove that it Is empty. I liave 
seen two casi»s of interstitial pregnancy that IxHrame normal uttTinc! 
pregnancies in tlie course of the thinl month as the fetus and its 
envelo|K*s grew into the uterine cavity from the tube. As a rule 
the interstitial pregnant tumor is separated from the uterus by a 
shorter pedicle than the pregnant rudimentary horn of a double 
uterus. 

The Diagnosis That Pregnancy Has Occurred Previously.— In mc^li- 

colegal cases the physician may be called upon to give an opinion 
28 



434 ABXORALVL UTERINE PREGNANCY 

whether or no a woman has ever borne a child. The answer will 
depend upon the physical examination alone. Folloidng preg- 
nancy the breai^ts are flabby and more or less pendulous, the 
changes in the nipples and areolae pre^^ously described are to be 
sought, also lineap albicantes on the breasts or about the lower 
abdomen or hips. A scar from a mammary abscess is good evidence 
of previous lactation unless other satisfactory explanation of its 
presence is forthcoming. 

By vaginal examination the hymen will be found destroyed and 
in its place the carunculao mjTtiformes, the vagina will show a 
certain amount of relaxation and absence of the rugae; lacerations 
of the perineum or pehic floor are proof of previous pr^nancy. 
The uterus will be found a little enlarged and the os will be found 
round, not the os tincae of \'irginity. A tear in the cervLx is proof 
positive of child-bearing unless there is a historj' of instrumentation. 
Erosions with endocervicitis must not be mistaken for lacerations 
and their effects. 

The Diagnosis of Multiple Pregnancy. — ^The diagnosis of multiple 
pregnancy rests on finding an unusually large uterus, a groove in 
the fundus separating the fetuses, hearing two fetal hearts, each 
\^ith a different rhj-thm, and on the palpation of two heads or two 
breeches. 

The Diagnosis of Pernicious Vomiting of Pregnancy. — ^Excessive 
vomiting of pregnancy or hypereniesis gravidarunij occurring most 
frequently between the third and the fifth week of pregnancy, is 
of three varieties, according to J. WTiitridge Williams, reflex, neu- 
rotic, and toxemic. In the reflex variety, the vomiting is apparently 
directly attributable to the existence of some abnormality of the 
generative tract such as retroflexion or anteflexion of the uterus, 
erosions or cicatrices of the cerN-ix, or an ovarian tumor, and it 
ceases promptly upon the correction or removal of the almonnality. 
The fact, however, that in many pregnant women the presence of 
similar lesions is not associated with serious vomiting would ap- 
parently indicate that its reflex origin is quite exceptional, and is 
e\idence that some other etiological factor is usually concerned in 
the pnxluction of the vomiting. The failure of suggestive treat- 
ment and the lack of e>idence of serious changes in metabolism 
make it improbable that the affection is neurotic or toxemic in 
origin. 



PERNICIOUS VOMITING OF PREGNANCY 



435 



In tlie Jieuroiic variety the vomiting is deix'ndent ujjon the 
existence of a neurosis — more or less clearly allietl to hysteria — 
wliifh may oi'eur in women wlio had manifested no signs of im- 
paired nervous control previous to the oeourrence of i>regnaiiey. 
In such cases careful examination will fail to reveal the existence 
of a single physical condition which could account for the vomiting, 
while the most accurate chemical analysis of the urine will afford 
no e\idence of serious metaliolic clisturbance; antl, finally, char- 
acteristic lesions will not Iw; found at autopsy in the rare cases 
which end fatally, as such patients die from star\'ation. 

Cure fre(|U(*ntly follows the {employment of api>arently usc^Iess 
measun*s ami unphysiological procedures, such as a \igorous 
le<'ture on the part of the physician, tlilating the cervax, applying 
k^LThcvs to the epigastrium, or the administration of an anesthetic. 
A rigorous rest cure or suggestive tr<'atment also may bring reli(*f. 

Toxemic vomiting, on the other hand, is a very serious disease 
and is a manifestation of a [irofoimd disurlmnce in metalx>lism, of 
the exact origin of which we are ignorant. All that wt^ know at 
{iresent is that it usually ends in deatfi, anil sometin^es leads to a 
fatal termination within a few days after the apfK^arancc of serious 
symptoms. In Kuchcasc\s the patient i>resents signs of a profound 
intoxicatit:)n, and may die in coma without any evidence of star- 
vation. 

The urine, while diminishc*d in amount as the result of the 
scanty intake of fluirte, does not contain albumin or casts until 
shortly bc^fore death, and may apparently present a normal amount 
of urea, as determined by the Doremus method, so that its casual 
examination gives no clew to the gravity of the condition. 

In reality, however, there is a decidinl decrea.sc in ttie amount 
of nitrogen excreted as urea and a marked increase in the amount 
put out as ammonia. Accordingly, while the total nitrogen output 
may be practically normal, the i>ercentagc of nitrogen eliminated 
as anunonia is greatly increased, ami this so-called '* ammonia 
c<x»flicient/' insteml of being 4 or 5 per cent as in normal pregnancy, 
may rise* to 20^ 30, or 40 jier cent. Moreover, the proportion of 
amido-acids is increaseil, and sometimes the acetone content is 
abnormally large. 

In making a ilifferential (hagnosis between the three varieties it 
is essential to eliminate the toxemic form by a cartful urinary 




436 ABORTION 

analysis. If the ammonia coefficient exceeds 10 per cent the 
diagnosis of toxemic vomiting should be made. If the ammonia 
coefficient is approximately normal the probability of a serious 
toxemic condition can be eliminated and the diagnosis will be 
between the reflex and the neurotic varieties. Some manifest 
lesion in the generative tract makes the diagnosis reflex vomiting. 
The suggestion has been put forward by F. P. Underhill and R. 
F. Rand {Archiv, of Internal Medtdne, Jan. 15, 1910, Vol. 5, p. 61), 
that the changes observed in the urine in pernicious vomiting of 
pregnancy are induced by the inanition which accompanies the 
severe grades of the disease and that the urine shows nothing 
characteristic until a stage of great prostration has been reached. 
They think that the supply of carbohych-ates to the system is the 
factor which determines the relative output of urea and ammonia 
and claim good results in the treatment of pernicious vomiting 
by the administration by enema of dextrose in solution. 



THE DIAGNOSIS OF ABORTION 

Definitions. — An abortion is the expulsion from the uterus of the 
products of conception before the placenta is formed, that is, 
during the first three months; a miscarriage is the emptying of 
the uterus of the fetus, the placenta and its membranes, from the 
Ix^gining of the fourth month until the child is viable, at the end 
of six and three-fourths months; and a premature labor is the 
delivery of the chikl after it is viable, or between six and three- 
fourths months and term. 

The word abortion is so frequently used to mean the expulsion 
of the products of conception at any time from the beginning of 
pregnancy up to the time of viability that it is convenient to so 
use it in this chapter. 

A complete abortion is one in which the fetus and its membranes 
are cast off entire; an incomplete abortion is one in which the fetiLS 
is born, but the membranes and the placenta, if formed, remain 
behind; a concealed or 7mssed abortion is one in which the embryo 
has perished but is not expelled; spontaneous abortions are those 
which occur without known cause; induced abortions arc those 
which are caused artificially and intentionally, whether by the 



ETIOLOGY 



437 



administration r)f flrugs or by the uso of intrunients, and habitual 
abortions are atmrtions rei>cateil in successive pregnaucie^s. 

Frequency. — Obviously exact figures as to the freciuency of 
alK>rlion?> are diflicult to obtain. Without doubt many oecur 
(luring the fir^it six weeks of pregnancy without attracting much 
attention, and many patients who have abortions are not uiuler a 
physician s care. J. Clifton Edgar found 6*35 eases of interruption 
of pregnancy — abortion » miscarriage, or preinaturt* delivery^ 
among 10,0(K1 cases of later treated in a disjx^nsajy servir-r in 
New York City, or one in every 15.7. Some authors give the 
frequency of alwrtions as once in cxi^ry five or six cases of lal>or. 

Aliortion proper is more apt to occur in niulti|>ani% while mis- 
carriages and prt^mature labors are found more commonly in 
pnmipara\ This seems to be clue to the fretjuency of uterine 
tiisease in muhipara^, so that with an hicreasijig nundwr of jireg- 
nancies the utiTUs tecomes progressively less tolerant antl ex[>els 
its contents earher with each successive pregnancy. 

Etiology. — The causes of abortion may be grouped in three 
elassf*s in the onier of their frequency: (1) maternal, (2) fetal, 
and (3) paternal. 

L The maternal causes are (a) constitutional and (b) local. 
a. Constitutional. Under this heatUog are to be classed tht* in- 
fectious djs<'ases, as tjiihoid fever, [jneumonia, smallpox, scarla- 
tina, cholera, especially if accompanied by high fever suddenly 
develo|>fHl, and tuN'rculosis and syphilis. Hyphilis in the mother 
is a very fre^juent cause of abortion, some authors going so far as 
to claim that it causes a quartt*r of all aix>rtions. 

Other causes of abortion are cardiac diseases, the toxemia of 
chronic neiihritis, diabetics mellitus, lead or arsenic |X)is4jning, 
anemia from sufiden loss of blood, the use of oxytoxie drugs, as 
ergot, cotton-root bark, quinine, aloes, and tansy. 6. Local causes 
are all thos<* conditions that cause* fx'lvic congestion, such as 
malpositions of the uterus, esp(^eially retrodisj>lacements, clironic 
endometritis^ lacerations of the cenix, and excessive sexual inter- 
course. 

2. The catiJ^es in the mmm and embryo are, an>1:hing that interhTes 
with the nutrition or pro< luces the dfath of the fetus. Many of 
them are secondary to pathological con<litions in the mother's 
itiasues* They are syphilis of the th^cidua or i^lacenta, and low 




438 ABORTION 

situations of the placenta, also, less frequently, anomalies of the 
decidua and the other fetal envelopes or of the fetus itself, pro- 
ducing injury or death. Introducing foreign bodies into the uterus, 
such as catheters or hatpins, must be reckoned as local causes. 
When the fetus is dead it acts like a foreign body and the utorus 
expels it. In exceptional instances the fetus may be retained in 
the uterus as long as two weeks after its death. 

3. The causes due to the father are chiefly syphilis transmitted by 
the spermatozoa. Sometimes there are syphilitic changes in the 
placenta and fetus where the mother shows no sign of the disease. 
Other causes are debility in the father, perhaps due to tuberculosis, 
perhaps to excessive indulgence in sexual intercourse. A French 
author has cited the instance of thirty cows who were served by 
the same bull within a short period of time. The fifteen that 
were served first went to full term, while the last fifteen aborted 
without an exception. 

Symptoms. — In abortion during the first six weeks there are 
seldom any prodromal symptoms. The woman may think she 
has a delayed and profuse menstruation, and may not realize that 
she is pregnant. Much blood is lost and clots are passed, and there 
may be pains in the region of the uterus. If she thinks she is 
pregnant and observes the clots she will think that she lias seen 
the fetus in the ''fleshy mass" that she has passed. The ovum, as 
a matter of fact, is generally passed first of all and is lost with the 
blood and clots. In the case of a complete abortion all of the 
embryo and its envelopes are passed at once and there is very 
little hemorrhage, the process lasting from twenty-four to forty- 
eight hours from the first hemorrhage or pain until all symptoms 
cease. Abortions are more apt to be incomplete, portions of decidua 
being left behind, and, in this event, hemorrhage continues. 

In abortion from the sixth to the twelfth week there are apt to 
be prodromal symptoms of fulbiess and weight in the pelvis and 
backache, indicating pelvic congestion. At this time uterine pains 
and hemorrhage are more severe and constitutional symptoms 
such as nausea, pallor, rigors, nervousness, and apprehension are 
often marked. After the third month the s)rmptoms of abortion 
are more like those of labor at term. The three stages of labor 
can be distinguished, the uterine contractions are more marked, 
and there are strong involuntary bearing-down efforts. 



DIAGNOSIS 



439 



Btagnosis. — The diagnosis of abortion dcfx^nds on the deter- 
niinatiori thai the patient is jiregnant; on the cliaraetiT of the pain, 
indieating uterine contractions; on the amount and character of 
the hemorrhage; on dilatation of the cervix; and on tlie ilescc^nt of 
the products of conception into or through the os uteri. Practical ly 
we are called on to distinguish between threatenetl abortion, in- 
evitable alxjrtion, and an alxnlion paiiiatly or wholly completed- 

The Dimjnihsis of Thrcak^ned Abf}rtu)n. — First w<* get the history 
to determine the prolmbility of the existence of pregnancy. If it 
can be* learned that the patient has missed a catamenia twice or 
even onee, if she has Imm exposed to impregnation, if she has 
exi*erienct*ci any disordei-s of digestion, or wUl tell of swelling of 
the breasts, or frequency of micturition, we may get valuable clews. 
Pain, if it indicates utt*rine contractions, is of a rh}ihmieai char- 
acter, Ix'ginning in the flanks and extending to the |)ubie region. 
Tlie disiinet character of the pain is more clearly marked in nii:^ 
carriages than in abortions proper and in the threateniHi abortion 
there is little or no pain. Hemorrhage is mmlerate in aniotint» 
bright in color, free from clots, and intermittent. Examination 
shows breast, changes (see section on normal uterine pregmmcy, p. 
421), pur|)lish discoloration of the vagina and cervix, the cervix 
soft| tlie OS somewhat dilated. The uterus is enlarged, the fundus 
is bulging forward, the lower uterine segment is compressible, and 
uterine contractions are infrequent- 

If, after a s<'ries of hours, the symptoms aljate and the cervical 
canal does not ililate. the o\iini does not descend, and uterine eon- 
tractions are still of infrequent oe-currence, the case may be said 
to be in the category of a threatenetJ abortion. 

The Diagnosis of hieviiable Abarlion. — If, on the other hand, the 
hemorrhage increases in amoimt, is persistent, and eontaiiLs clots 
and fragments of fetal structures, pain is considerable and increas- 
ing in severity, and local examination shows that the o\'Tjm has 
move*! dowii in the uterus, as att4>ted by the eUmination of the 
angle of anteflexion between the large anterior funilus and the 
eer\ix, while the ovum can be felt by the tip of the examining 
finger through the thlated os as a soft bag, uterine contractions 
being frequent, the case is one of inevitable abortion. 

An ovum may be differentiated from a blood clot by noting 
that it increases in size during a uterine contraction, becomes 




440 ABORTION 

smooth and tense, and advances, while the blood clot is not tense 
and does not advance; also, the ovum presents a convex surface and 
is elastic, while the blood clot is cone-shaped with its apex down- 
ward and is not elastic. All clots or tissue passed should be floated 
out in water and examined with a magnifying glass for decidua, 
fringe-like chorionic tissue, or bits of placenta, the tissue being 
examined subsequently under the microscope. 

The Diagnosis of Abortion PartiaUy or Wholly Completed, — To 
determine whether all or a part of the contents of the uterus have 
been expelled it is necessary to have everything which has been 
passed from the vulva preserved for careful inspection. To this 
end the napkins worn by the patient should be saved, and, before 
emptying the bladder or bowels she should sit on a chamber and 
strain so that the contents of the vagina may be expelled into 
the chamber for preservation. The ovum, being small and sus- 
pended in the liquor amnii, is usually lost when the membranes are 
ruptured early in the course of an abortion, being passed from the 
vagina at stool. Parts of the decidua are more often left in the 
uterus than not. In very early abortions the pieces of tissue can 
be felt with the tip of the uterine sound palpating the uterine 
cavity. When there is any foreign substance in the uterus the 
cervical canal will be found open. In pregnancy exceeding three 
months' duration the finger can be passed into the uterine cavity and 
will feel the bits of fetal membranes or portions of placenta still ad- 
herent to the walls. The Emmett curette forceps will bring away 
tissue for examination. If the tissues appear to be in any respect 
abnormal they should be sent to the pathologist for examination. 
The finding of an intact ovum settles the question of a complete 
abortion. The disapi)earance of the secretion of the breasts is an 
important sign that an abortion is complete. If the alx)rtion is 
completcM^I the uterus will be found contracted and the uterine canal 
closed. In missed abortion the dead fetus may ho retained in the 
uterus for some time; there are no i)ain and no hemorrhage, but 
the cervix remains soft and the os patulous. 

The Diagnosis of Miscarriage. — ^The diagnosis of miscarriage is 
generally easier than that of abortion because the signs of pregnancy 
are definite and pronounced and the same may be said of the 
symptoms (see the diagnosis of normal uterine pregnancy, page 426). 

Differential Diagnosis. — ^Abortion must be differentiated from 



HYDATIDIFORM MOLE 



441 



extra-uterine pri*gnaticy and from nienorrha*j;ia, metrorrhagia, 
and dysmenorrhea. In alx»rtion the hemorrhage is generally 
greater in amount and the clots are more frequently passeil than 
in early extra-uterine pregnancy after rupture; the pain is much 
less severe in abortion and is of the uterine contracture variety, 
that is, beginning as an aching in the flanks and radiating to the 
hypogastriun^, whereas in extra-uterine prc^gnancy the pain is 
severe, agonizing, and in the lx*ginning is unilateral. The clianges 
in the uterus are more marked m abortion than in extra^uterine 
pregnancy^ and in the latter some tumor of the achiexa can be 
determinerl. It is to Ije remembered that a ut-erine decidua is 
fornu^I bi the ease of extra-uterine pregnancy and this is apt to be 
passed early. 

Menorrliagia and metrorrhagia are exeludeil by the history, 
which excludes prc^gnaney, and by the absence of the symptoms 
and signs of pregnancy, also by tleterniining some cause for the 
increaaeii flowing, such as a fibroid tumor, endometritis, or cancer. 
Dysmenorrhea is excluded by the past, history of pain occurring at 
some definite interval of time bc^fore, after, or during the flow, and 
by the absence of the symptoms and signs of pregnancy. 



THE DIAGNOSIS OF HYDATIDIFORM MOLE 



Hydatidiform mole, also called vesicular or cystic mole, is a dis- 
ease of the chorion consisting of a cystic formation at the ends of 
the villi, producing a nia^s that rescfuibles a bunch of grapes. It is 
a rare tUseasc occurring once in atout three thousand cases of preg- 
nancy and is found oftc^nest among multipara- Ix'twetm the ages of 
twenty-five and forty. It b apt to Ix^ re[x*attHl in successive preg- 
nancies in the same patient. The mole generally develops before 
the fourth month and caust^s the death of the fetus. 

Pathology- — The cystic pn:»cess wliich involves the chorion 
is, accordbig to Marclmnd, an edematous degt»neration in which 
the S3mc>iium {tlays an important role. Large masses of sjTicy- 
tlum and chorionic epithelium invatle the decidua tmd the 
uterine walls just as in chorio-epithelioma, the process resembling 
this disea^ which foUows hy^latidiform fiiok* in alx>ut half the 
cases. The translucent vesicles are similar in shape to the elements 





be a small tumor involving only the placental portion of the chorion. 
Tlie maas is exj^elle*! by the yteru^^ as a rule in the fourth or fifth 
month with labor jmins and hemorrhage, but portions of the cystic 
mass are apt to be closely adherent to the uterine wall so that 
some IS apt t^ be left behind, necessitating a curetting. The fetus 
may be destroyeil in cases of c?d<*nsivc disease, or it may be pre- 





DIAGNOSIS 



443 



scTveil in cases of minor involvement. It is generally killed early. 
Sometimes, when the uterine blotxl- vessels are eroded, the hemor- 
rli:i^e from hyilatidiform mole may Ix; excessive. 

Symptoms."— In tlie first few w*eeks of pn^^nancy there is no 
means of distinguishing eyslic diseast^ of the chorion. As the 
pregnancy advances the uterus containing hydatiiliform mole 
increases in size more rajndly than in the case (»f normal pregnfiney, 
aiKl hemorrhage occurs with a bloody, watery discharge, wliieh is 
not unlike currant-juiee in appearance* 

Diagnosis* — The diagnosis rests on the symptoms and on a 
doughy feeling of the uterus on liinianual palpation, this king 
demonstrable after the third month when tlie rapid growth of the 
uterus becomes apparent. If the eysts are found in the vaginal 
discharge the diagnosis is certain. No fetal movements or heart 
sounds are heard anil there is no ballottenient. 

The possibility of the development of chorio-e})ithelioma follow- 
ing hytlatidiform mole should never be lost sight of, and every 
pati(*nt should Ix* ke|>t under close obtscrvation for at least a month 
after the expulsion of the mole. 



CHAPTER XXIII 
THE DIAGNOSIS OF DISEASES OF THE URETHRA 

Anomalies, p. 444: Persistent urogenital sinus, p. 444. H^'pospadias, 
p. 444. Partial defect of the external urethra, p. 444. Epispadias, p. 445. 
Atresia of the urethra, p. 445. 

Displacements of the urethra and alterations in form, p. 445: Upward 
dislocation, p. 445. Downward dislocation, p. 446: Diagnosis, p. 446; 
Differential diagnosis, p. 447, Urethrocele, p. 447. Suburethral abscess, 
p. 447, Dilatation of the urethra, p. 447, Dangers attending dilatation, p. 
447, Prolapse of the urethral mucosa, p. 448. 

Inflammation of the Urethra, Urethritis, p. 450 : Acute urethritis, p. 450. 
Chronic urethritis; (a) Diffuse; (6) Circumscribed, p. 451: Latent 
gonorrhea, p. 452. 

Stricture of the urethra, p. 451. 

New growths of the urethra, p. 453 : Urethral caruncle, p. 453. Polypus 
of the urethra, p. 455. Primary Cancer of the urethra, p. 455. ^Sarcoma of 
the urethra, p. 456. 

The anatomy of the urethra and the methods of examination 
and the technique of endoscopy will be found in Chapter VIII., 
page 100. 

ANOMALIES 

The congenital defects of the urethra are: absence of the 
urethra, hypospadias, dilated short urethra, epispadias, and 
atresia. The development of the urethra and bladder is shown in 
the diagrams from Schroeder in Chapter XXI., page 395. Where 
the urethra has failed entirely to develop the bladder opens directly 
into the vagina, and the case may be regarded as a persistent 
urogenital sinus. Several of these cases have been reported in the 
literature, but more common are the instances of lack of (Uwelop- 
ment of the lower portion of the urethra. If the part lacking is the 
posterior urethral wall the case is one of hypospadias y and if both 
anterior and posterior walls are absent in the lower com-se of the 
lU'ethra it is a case of partial defect of the external urethra. In cases 
of absence of the vagina the urethra is commonly found dilakd 
and short, in some cases being of large enough caliber to admit 

444 



DISPLACEMENTS OF THE I IIETHIIA 



44.: 



the penis. Many authors have assumed that the large size of the 
urethra in such patients is due to forcible dilatation during coitus, 
but as the large urethra is found in unmarried women who are 
the subjects of aljseiiee of the vagina — in i>aticnts who could 
never have been subjtTted to sexual intereourse — the condition 
of tht^ im:!thra must I>e regai\l<'d as ilue to a partial jx^rsistence of 
the urogenital sinus. Iiiterconrse has undoublcilly taken place 
through such a urrtlira ui many mstanei*s, but we must not. ivgard 
the dilatation by the [jeais as tin? primary cause* of the large 
calilx^r. 

Epispadias is a defect of the upfN^r wall of the urethra asscx-iated 
with separation of the labia minora and divisii»n of the clitoris. 
In extreme cases of epispadias then^ is also exstrophy of the bladder 
togetlier with ileficiency of tin* anteritir Ijladder wall. Thi* con- 
dition is rare, as is atrcmu of the urdhm, wliich is su])pos{vl to Ix^ 
due to inflammatory affections late in uitra-uterijie life causing 
more or less complete occlusion of the urethral canal. TIutc must 
l>e some avenue of escajx* for the m-ine even Ix^fore l>irth or else 
the child has great distention of the alxlomen from ovcTfillcd 
blatkler, ureters, and kitbieys. Partial atresia may be relieved 
scMjn after l>iiili by ]>assing a sound, as in the case reportetl by 
MantU and citeii by Kelly, in which a chikl two days old had vom- 
iting anil convulsions until the atresia of the urethra was broken 
down by a sound. 



DISPLACEBffiNTS OF T^ URETHRA AHB ALTERATIONS 

IN FORM 

Upward DieuxrATioN of the 1^r?]thra 

Uptmrd dislocutiuu of the urelhra may occur from dragging on 
the liladtler aiid thi' urethra in the case of large tumors and m 
pn'gMancy* It is sui>iKxs<.n_l that the tracti(in on tlie neck of the 
bladtler may be the cause of frequency of mitiation, which sonitv 
times occurs in these castas: more often there are no symptoms 
at alb lUirely there is retention of urine, and the catheter, 
when pa^st^b traverses a long route u{> behind the pubic bone* 
A soft rubber catheter is safer than a glass or silver one in such 
cases. 




446 DISEASES OF THE URETHRA 

Downward Dislocation of the Urethra 

Dovmward dislocation of the urethra is a fairly common lesion 
resulting from child-birth. The entire urethra may be torn from 
its pubic supports, as in the case of procidentia, or only the upper 
portion may be freed from its fastenings. Not infrequently 
careful examination will reveal dislocation of the upper third of 
the urethra in cases where prolapse of the uterus is not present. 
We must suppose that in these cases the uterus and its ligaments 
have involuted and regained a normal state, while the simdered 
tissues under the pubic arch are unable to support the urethra 
in a normal situation. Downward dislocation of the urethra 
may be attended by no symptoms, or the patient may experience 
sudden stoppage of the urine during urination, or there may be 
partial incontinence. The tone of a dislocated urethra is apt to 
be below par, therefore such a urethra is more likely to become in- 
fected than is a normal one. 

Diagnosis. — The diagnosis is established by palpation of the 
urethra with a sound in its canal and a finger in the vagina, also 
by inspection of the vagina while the sound passes through the 
urethra, the patient being in the dorsal position. For this purpose 
employ a sound that is about three-sixteenths of an inch in diam- 
eter or a Kelly urethral dilator of the same caliber (4 millimeters) 
so that this larger sound may occupy the entire lumen of the 
urethra, and thus indicate the true course of the organ, and not 
— ^as would be the case with a small sound — enter a diverticulum, 
if present. With this sound passed so that its tip is just below the 
neck of the bladder, tilt the point downward and note whether the 
lU'ethra is held to the os pubis or goes downward into the vagina. 
Next substitute a uterine sound for the dilator, bend the terminal 
inch of the sound to an angle of thirty degrees, and introduce it with 
the point downward. If the upper third of the urethra is dislocated 
downward the point of the sound, following the course of the 
displaced urethra, may be seen and felt in the vagina. 

In my private case records are the notes of fifteen cases of down- 
ward dislocation of the urethra not associated with uterine prolapse. 
In cases of uterine prolapse with accompanying dislocation of 
bladder and urethra, the course of the urethra in the prolapsed 
mass is mapped out with the bent sound in the urethra. 



DISPLACEMENTS OF THE I RErfHRA 



447 



Dtfferentml Diagnosis. — We must (liflfcrentiate urethrocele^ which 
is a pocket in the lower wall of the urethra — generally in tht^ 
niidtile third of its course — from clowiiwanl disloealioii of the 
urethra. This is done by noting the general course of the iiretlu-a 
by means of a large sound or Kelly ililator pasvsed to the neek of 
the bladder. Withdraw the sound and pass a bent probe through 
the o|K?ning in the urethral wall into the urethrocele, following the 
point of the jirobe with a fingi r in the vagina. Next pass a cysto- 
scope into the urethra anil see the oix*ning into the urethrocele, 
passing a prolx* tlirough the eystoscojx^ into the urethrocele to 
verify the tiiagnosis. Urine may collect in a iu"etIirocele, deeom- 
|x:»se, and set up a urethritis. The urine is ejected 1 during the act 
of cougtiing, laugliing, or strauiing, and the patient complains <>f 
this stjrt of incontinence. 

Disloeation of the urethra downward must te differentiated 
from suburethral abscess^ an abscess occupying the urethro-vaginal 
septum, varjnng hi size from a cherry to a hen's egg. Sueli an 
abscess has a chronic course and is supposeil to originate in Skene's 
glands, in a tliverticulum from the urethra! canal, or in a supimratr- 
ing cyst of the urethro-vaginal septum. It is the seat of pain and 
soreness during urination, defecation, and coitus, the latter often 
being impossible of acenmplishrnent because of the tenderness of 
the vagina. The aKsce^ generally opens into the urethra by a 
minute 0])ening; and pressure on it through the vaginal wall eausc^s 
the sac to collapse lis it is emptic**!. In some cases the i>atient 
experiences |KTiodic discharges of pus from the urethra. If the 
cystoscopc is pavssed up to the vesical neck and withdrawn, a few 
ilrops of pus will Ix' seen to gush into its lumen after the tip of the 
cystoseojxi has passcnl the oixniing into the aKscess. A probe 
passed into the o|X'ning and pal|>ate<l per vaginam establishe,s 
the diagnosis. 

Dilnltitkyrt of the Urefhra. — Congenital enlargement of the urethra 
has Ix'en referred to in discussing the anomalies as a manifestation 
of tlie ixi-sistence of a urogenital sinus. Stricture or tumor of 
the urethra if situat***! near the meatus may cause dilatation of the 
mrethra Irhind tlie stricture *>r tumor. 

AH of the structurt^ of the urethra are hypertrophied during 
pregnancy and Skene thought that the urethra was dilated at 
that time. Artificial dilatation has been eauBed by coitus per 




448 DISEASES OF THE URETHRA 

urethram and by introducing foreign bodies into the urethra for 
purposes of masturbation, and, also, dilatation of the urethra was 
formerly practiced by physicians for the purpose of digital ex- 
ploration of the bladder for suspected stone or tumors of that organ. 
The urethra is extremely tolerant of dilatation and bladder stones 
as large as an inch in diameter have been passed spontaneously 
through the m-ethra, followed by only temporary incontinence. 
Nevertheless, forcible dilatation of the urethra to a diameter of 
more than half an inch (12 millimeters) is entirely unjustifiable, 
because permanent incontinence is very apt to be the result. Few 
physicians possess a forefinger whose knuckle at the end of the 
first phalanx measm-es less than three-quarters of an inch (18 
millimeters) in diameter and most forefingers are much larger. 
The interior of the bladder can not be palpated miless this knuckle 
is passed into the urethra. Examination with the little finger is 
inade(iuate, although the lower portions of the bladder may be 
reached with its tip. Modem methods of cystoscopy do away 
with the need of digital exploration and we may subscribe to Dr. 
Thomas Addis Emmet's vigorous statement to his students in the 
old days at the Woman's Hospital, that the man who dilates a 
woman's urethra with his finger should be put in jail. 

The diagnosis of a dilated urethra is made by observing pouting 
of the meatus, and a distinct ridge in the vagina corresponding 
to the course of the urethra. By touch per vaginam the enlarged 
urethra may be felt as an elastic, roUed-up, membranous tube, 
and on introducing a large Kelly dilator into the uretlu-a, it slips 
easily into the bladder. Moving the tip of a uterine somid about 
in the urethra we determine an enlarged canal, and by palpating 
the sound per vaginam we learn the thickness of the tissues of the 
urethro-vaginal septum. The No. 12 cystoscope passes easily, 
and the larger sizes of the urethral dilators introduced successively 
will tell of the exact diameter of the urethra. 

Prolapse of tlie Urethral Mucosa, — ^This rare affection consists 
of an eversion or turning out of the urethral mucous membrane 
through the meatus. For some reason the hypertrophied mucosa 
becomes loosened from its attachments and is extruded from the 
external orifice in the shape of a deep red or bluish tumor with 
the orifice of the urethra in its center. The extreme grade of this 
affection is most often found hi debilitated old women and in 



young chiklren; a moderate amount of cversion may occur in any 
woman who has had children. In the pronounced grades the 
prolapsed mucous membrane may become edematous or even 
gangrenous. The dia^osis Is made by di.scovering a deep red 
tumor in the situation of the vestibule, that is covered everywhere 
with viihWy bleeding mucous^ membrane, ami has a slit in its 
center that gives aecet^s to the bladder. If only a portion of 




Pio. 183. — Pmlapse of the Urethral Mucous Membrane. (Montgomery.) 

the circumference of the urethra is involved in the prolapse the 
everted nmcosa may be mintaken for a |K>lypus, a uretliral carmiele, 
or eversion of the bimlder mucosa. If the prolapsed mucous mem- 
brane is s(*ize<l with a d<»lieate [mr of forceps and dra\\Ti dowTi it 
will be found to have a broad Imsi* ami will be inereased in size; 
in the case of a polypus or caruncle drawing the tumor down will 

show a ptxhele, and no increase in size beyond the elongation duo 
2Q 




1 



450 DISEASES OF THE URETHRA 

to traction. In many cases the everted mucosa may be replaced 
in the urethra by the use of cocaine and taxis. 

If the case is one of eversion of the mucosa of the bladder, the 
sound passed into the urethra can be made to sweep entirely around 
the tumor, and when passed further there is no bladder cavity to 
receive it. By taxis and pressure with a large-sized sound the 
prolapsed mucous membrane may be pushed into the bladder. 
Cystoscopy will show the distended bladder and the portion of 
the lining that had been prolapsed to be of a deep red color. 



INFLAMMATION OF THE URETHRA: URETHRITIS 

Urethritis is a common affection in women, though not so often 
diagnosed as in the male; "irritable bladder" and "cystitis," in 
the place of an exact diagnosis, often meaning urethritis. With 
the more general use of the endoscope we are learning more of 
this disease. It is most often due to the gonococcus, but may be 
due to an extension downward of a cystitis, to traumatism — ^as 
from injuries during childbirth or from the passage of a calculus — 
to urethral new growths, or to an extension upward of a vulvitis. 
The disease is limited to the mucous and submucous tissues, which 
are injected, swollen, and secrete pus; the upper and lower portions 
of the urethra being more often affected than the middle part. 
Urethritis occurs in two forms, acute urethritis, and chronic ure- 
thritis, the inflammatory process having a marked tendency to 
Im-k in Skene's glands. This is true especially of the gonococcus 
form, which may be cured apparently, only to be lighted up anew 
into an acute attack when the gonococci have found fresh culture 
material in another individual. 

Acute Urethritis. — ^Acute urethritis begins with burning and 
itchhig in the neighborhood of the urethra, followed in one or two 
days by painful micturition. The body temperature may be 
elevated and anorexia and lack of energy may be present for a 
short time. The patient notices that her linen is discolored by a 
purulent discharge and even by blood; for there may be bleeding 
in the most acute stage. The local examination should be made 
before the patient has urinated. The dorsal position is used. A 
drop of pus appears in the meatus and the mucosa at the orifice 



URETHRITIS 



451 



of the urethra is injeetiHl, red, and swollen. Stroking the urethra 
from above downward by a finger in the vagina, piis issues from 
the orifice of the urethra. If it d(x\s not come from the urethra 
it may be expressed from the openings of the canals of Skene's 
glands» which are situatcil one on each side m the lower i>ortion 
of the labia urethra* just inside the meatut?. The finger in the 
vagina notes increaseil body heat and tenderness of the urethra. 
In this acute stage it is just as well not to use the endoscope bo 
cause of the damage it must inflict on the inflamed mucosa. If it 
is used with the aitl of a strong solut ion of cocaine, the mucous 
membrane is sc^n to be bright red and bleeilmg easily and pus 
issues from between the fiKlds and from the minute glands, or there 
are to be seen linear ulcers two to four millimeters long an(J one 
millimeter broad, generally on the i>ost(Tior wall. Great care 
should Ije excTcised not to introtluce the enilost^ope (Kelly Cysto- 
scojx* No. 8) beyond the bladder neck, for fear of infecting the 
I>ladder. Smears should be ma*ie and examined for the gonocoecas. 
Concomitant inflammation of on<^ or both of Bartholin's glands 
indicates probable gonococcus infection. 

Chrome Urethritis* — Chronic urethritis is the form of urethral 
inflannnation most often scnm by the gjmecolfigist. It conmionly 
follows acute urethritis, although the latttT may have given very 
few symptoms and may not have been diagnosis L 

The disease is diffuse or circumscTibcxh 

(a) Diffuse Chrome Ureihrii is. ^Thh generally follows acute 
urethritis. The longer the inflaramaiory process has existed the 
paler becomes the mucosa and the greati^r the thickening of the 
mucous and submucous tissues because of new fcjrmation of con- 
nective tissue. In the later stages of chronic urethritis the uretlira 
is felt as a hard tube> only inrwlerately tender to ttHicti. The symp- 
toms may be nothing more than itching or burning in the region 
of the urethra and |>erhai>s frequency of micturition. There is some 
swelling anil a gelatinous and granular condition of the mucosa 
at the external orifice. The mucosa pouts out into the lumen 
of the endoseojie so that the canal apjx^ars chjsett ; it is dull red in 
color, granular and soft, and the laconte, cr^pts^ and ofx^nings of 
the glimds show as deeiMi* red s[>ots, i>erhaps giving exit to pus. 
The disease is most often met with in prostitutes. 

(5) Circimiscribed Chrmic Urethritis. — In this form one sees 




452 DISEASES OF THE URETHRA 

through the cystoscope patches of pale, almost gray mucous mem- 
brane surrounded by the pale red, normal mucosa. Later the 
pale areas become whiter still as they represent scar tissue, and 
they sometimes form strictures of the urethra. When, the specu- 
lum is passed through such cicatricial areas they show decreased 
elasticity and tear easily, causing bleeding. The chronic inflam- 
mation may be limited to the region of Skene's glands. In this 
case there will be reddening about the orifices of the ducts of the 
glands and pressure through the vagina will express a drop of pus 
or turbid serum from the gland. The discharge is apt to be thin 
and serous in the chronic cases, and gonococci are few. Careful 
search for this organism should be made. Skene's glands are 
among the chief lurking places of latent gonorrhea, the other most 
frequent situations being the cervical canal and Bartholin's glands. 
If the gonococcus can be isolated from the discharge from either 
of the latter organs, even though it is absent in the urethral dis- 
charge, the inference is that gonococcus infection of the urethra 
is present also. Several microscopic examinations should be made 
from the discharges from each of the three situations before pro- 
nouncing that gonorrhea is absent. 



STRICTURE OF THE URETHRA 

Van de Warker as long ago as 1887 called attention to the fre- 
quency and importance of strietures of large caliber in women. My 
own experience has taught me that such strictures are relatively 
frequent and are found by the physician who does a good deal of 
cystoscopic work. In my private records are the notes of nine cases 
that I have seen, and Pasteau (quoted by Knorr) saw twelve cases 
and had collected one hundred and twelve from the literature. 

Strictures arc caused by chronic gonorrheal urethritis, by in- 
juries of the urethra during labor, by cicatricial contracture of the 
anterior vaginal wall, due to a slough, or very rarely to cicatriza- 
tion of a chancre, or carcinoma of the urethra. Stricture at the 
meatus sometimes results from kraurosis vulvae. 

The symptoms of stricture are: painful and difficult micturition, 
the urine being passed in a small stream. A small meatus is very 
commonly met with in women and is diagnosed by passing the 



NEW GROWTHS OF THE URETHRA 



413 



fODical calibrator. Any mea^surement in the atlult under 6 niilli- 
riieters must be clasBed as snialL A strieture is detected by past^iiig 
the grailuated urt'thral lUlators and noting the situation and size 
of the point of resistance. Through the cystuscope one sees iiTog- 
ular rolling-in of the mucosa and asynnnetry, the strictured portion 
being whiter than the surrounding mucosa, non-elastie, and bleeiliiig 
if stretelied. 



NEW GROWTHS OF THE URETHRA 

The new growtli^s observed as occurring in the urethra are car- 
uncle, polypi, cancer, and sareoma. 

Urethral Caruncle. — Urethral raronclc is the term used to denote 
a highly vascular tumor which projects from the urinajy meatus. 
It is a common affection. Lange has describetl thrf« forms ac- 
cording to their pathology ; (a) granuloma, {b) papillary angioma, 
and (c) telangiectatic non-pai)illary mucous polyp, 

a. The gi'anuloma is characterized by infiltration of round cells 
and abundant eapillarias, and is the result of a gonorrheal lesion of 
the urethra, fc. Papillary angioma is a highly vascular mucous 
|>olyp. It has a covering of pavement epithelium with nipi>le-like 
elevations, and is inva<l(xl by connective-tissue elements, c. The 
telangiectatic variety is characterized by an abundance of thiu- 
w*alle(l capillaries, these being so dilatefl often as to give the tissue 
a cavernous character; they may even contain cysts. Tins tumor 
han no papilla?. 

All three varieties arr^ found with equal fref|uency in middle life, 
the granuloma is more often found in yoimg women Ijetween twenty 
and forty% and the papilloma variety in women over forty. As a 
rule, urethral caruncle is obec^rved late in the ehildbearing [XTiod 
of life, although it may be founrl at any age from childhood to olfl 
age. The symjitoms are excessive |)ain on urination and sensitive- 
ness of the vulva, even to the slightest touch, also frequency of 
micturition and derangement of the nervous system. Patients 
may hoKl their urine for long jieriods of time to avoid the {>ain 
ex|>erience<l on jmssing it. Pains, which w^e may call sympathetic, 
ratliate in all directions from the {K'Ivis, just as in vaginismus. 
One of my patients eomplaincil of a spasmodic drawing up of one 





Fro, 184.— Urethral Caruncle, (Montgomery.) 

the labia one sees a brilliant red growth projecting from the mc 
It may look like a cock's comb or a very small raspberry and varies 
in size from a BB shot to a eherr>% — large ones being unusual. 
Its surface is generally smooth, but may l>e rooghene«i like the 
surface of a raspterry. The growth generally springs from the 
IKJst^rior wall of the urethra just inside the meatus and is either 
pedunculated or sessile. With a few exceptions urethral caruncle 



L 



NEW GROWTHS OF THE URETHRA 



455 



is exquisitely sensitive; now and then a non-sensitive tumor is 
seen. It bleeds easily, but ilcws not, as a rule, bleed enough to 
soil the patient's linen, but a purulent vai^inal discharge is a coninion 
accoinpaninient of thesi* ^o\\ths, perhaps Ix^cause they are fre- 
quently of gonorrheal origin. They are of slow growth and almost 
always twiit ivhen removed imless every bit of tumor tissue has 
been taken out; but the reciurent growth is Hke the first, and tlif^n* 
is no tendency to malignancy or to extension beyond the original 
site, A thorough diagnosis can not be made often without cocaine 
or an anesthetic. The meatus must be dilated with the conical cali- 
brator and the exact situation and extent of the base of the tumor 
determined by the aid of the cysloscopc. 

Polypus of the Urethra, — Certain forms of canmcle are polypi, 
as already stated in the considiTation of caruncle. Mucous i>o!ypi 
situateil in the middle ami upper urethra are very rare. They 
cause few symptoms and an^ to be seen through the endoscoi>e. 
A few cases of fibroma of the urethra have been described and 
one or two cases of myoma. 

Primary Cancer of the Urethra. — This is a rare disease, there being 
on record in 1903 only niru! authentic cases. Secondary cancer 
of the urethra, on the other hand, is not so uncommon. The 
primary" ilisease is a disease of older women and seems to start in 
the tissues about the lower urethra more often than in the urethra 
itself and to invade the mucous membrane late. Strictly spc*aking, 
only the form of cancr*r lx*ginning in the lu^ethral tissues should 
bi* classed as cancer of the urethra, but after the mucous membrane 
has been destroyeil the differentiation of the primary point of 
origin is necessarily difficult. The disease must Ix* differentiated 
&om caruncle, chancre, anti tuterculosis. In caruncle the tmnor 
is soft and does not increase in size; it is situated in the urethral 
canal, generally on the ix)sterior wall. In the case of primary cancer 
the gro\\i^h is lianl and is si^dom s^i'cn I:H:*fore it has involvcnl a 
wide area. The ulcer of a chancre follows a suspicious intercourse 
with a definite periotj of incubation, twenty-six days. It heals m 
a short time, leaving a scan The ulceration of cancer is of long 
duration, it extends to the surrounding parts, and the history of 
infection is atxsefit. Perhaps the Spirochs'ta pallida can Ix* isolated 
from the discharge. In the case of a tuberculous ulcer the cheesy 
matter and the tubercles, characteristic of tuberculosis, may be 




456 DISEASES OF THE URETHRA 

seen by the naked eye, and there is Httle or no mduration of the 
base of the ulcer as in the case of both cancer and chancre. In all 
doubtful cases a piece of tissue should be excised for microscopic 
examination. 

Sarcoma of the Urethra. — ^This is a very rare disease, only four 
cases having been reported. Three of the cases were in women 
fifty years of age or older, and the fourth in a child of three. The 
symptoms are bleeding and the presence of a tumor in the situation 
of the urethra. The tumor is to be removed and examined under 
the microscope. 



CIL\PTER XXIV 
THE DIAC.NOSIS OF DISEASES OF THE BLADDER 

Anomalies, p. 4.57: Absence of the hlaiider, p. 4.'»7. Doiil»le bIndtIi.T, p, 
458. Loculate bladder, p- 458. EpiMpntiiiis nml exstrojiliv of ihe bladder, 
p. 45f>. 

Alterations in form, and dispkcemeiitfi, p. 451); Disiended bladder, p. 459. 
Rupliire of Ihe bladder, p. 4150. CViiitnution of Ibe bbdder, p. 4Cil. Uf>- 
ward ilisplacenieiif, p. 4(iL Dowiiwjtrd displac^enieiit, p. 4G1. Luteral 
ibsplac-ernent, ji. MH, Hernia of the bladder, p. 402, E version of the 
bladder, p. 4ii2. 

Foreign EocJias in the bladder, p, 4<i^: Calculi, p. 462, Other forei^ 
bodies, p. 463. 

Cystitis, p. 465: Classification, p. MieJ: Etiology and pathology, p- 466: 
Cntarrhal cystitis, p. 407; T'lcerative cyslilis, p. 468; Exfoliative cvHlitis, 
|j. 4**8; Tybereyloys cystitis, p. 4G8. Certain rare forms of cystitis, p. 476, 
Synififonis of cystitis, p, 47L Diagnosis of cystitis, p. 471* 

Varix of the bladder, p. 474. 

Fistiilie of the bladder, p. 474; (1) Vcsfco-vaginal fislula, p, 474; Fre- 
quency, etiology and pathology, p. 474; Symptoms, p. 476; Diagnosis, p, 
477: Differential Diagnosis, [). 478. ('2) Vesicti-iilcrine fistnla,p, 470; Vesico- 
utero-vaginal fistnla, p. 471). (il) Vesico-intcstinai and other fistulie, p. 470, 

New (irowthsof the bladder, p. 486: Symptoms, p. 481. Diagnosis, p. 
481. Benign tumors, j). 485; Papilloma, p. 48:i; Fit>ronui and Myiirna, 
p. 483; Adenoma, p. 483* Malignant tumors, p. 483: Carcinoma, p. 483; 
Sarcoma, p. 484 » 

Functional DisturlMinces of Itie bladder, p. 485. 

The anatomy and technique of exanunation of the hlarli let- 
have Ix'eu cleseribcHi in Chapter VIII., page 107. 

The tliagnofiis of diseases of the bla^^lder ih made by Htudy of the 
history, by analysis of the urine, and by direct exatuiiiatinn nf the 
organ by means of palpation of its exterior and by insi>ection of 
iti* illuminated interion 



ANOBIALIES 



Absence of the bladder is a very ran^ malformation and is generally 
assoeiatetl with a mm-viable child. In these eases the imiters 
teniimatc in the uretlira, the rei'tiim, or the vagina. 



467 




458 



OF THE BLADDER 



Double bladder is another very rare nialfonnation, which is apt 
to be assoeiateil with duplication of the other pelvic organs, as hi 
a case reported by Sujipiiiger, in which there was a double bladder 
anil also double urethra, elitori?^, hymen, and anus, ea^:"h half of 
the pt*Ivi*s containing a ut<*rus unicornis, an ovary, and a tube. 

Loculate bladder^ or a bladder prewnting congenital ixickots or 
(iiveilicula which projeet outward from the main cavity of tht* 
bladder, is not so rare, and the same may be said of a bladilcT 
partially di\q(le<l by a median septum. The congenital loculate 
bladder is not to \h^ cotifused with the bla<ider pocketed by calculi 
or by inUanmiatury disease, neither is it to be classed as an instance 



V 



FiQ, 185.— The Base of the Bladder sbowmg Diverticula. (Knorr.) 

of su]x*mumerar\^ bladdei"s or double bladder, ab^ady raentionecL 
Th(* diagnoj^is is established I>y olx^erving the lot*uli through the 
cystoscope and noting that they are scparateil by ridges of mucx>its 
menibranf\ and not by scar tissue, the latter being hartl and white, 
and the fornier soft anil pink, 

A. L. Chute (Bostim Medical and Surgiad Journal, March 22, 
1906, p. 309) lias ealltHJ attention to a ca^ in which a di\Trtictiluin 
of tlie bladder existeil as the result of a previous suprapubic 
cj'stotomy^ the pocket acting as a storehouse for organisms that 
had perioilicaUy reinfecteii the bladder. In the same paper he 
mentions a congenital diverticulum, diagnosed by the cj'stoeeope, 
that acteil apjmrently in the same way* 




ANQMALIES AND DISPLACEMENTS 



459 



Hyj3ospadiaSj a coiKiition (jf {>ersistent urogenital mms, has 
been referred to under diseases of the urethra. 

Epispadias and exstrophy of the bladder are rarer in tlie fi-niale 
than ill the male aiul are very sc^ldom met. There is a failure of 
development in early filial life Ixith of the anterior wall of the 
blackler and of the anterior alxlorTiinal wall over the blatlder, and 
if the entire front wall of the hladiler is wanting, ihv symphys^is 
piil)is is absent als<i. The postiTifjr wall of the bladiler appeai-s as 
a bleeiling, reddened, rouii<leii mass w^here the symphysis should 
be. just above the orifiee of the vagina, an<i in its surfaee the 
o|3enings of the ureters can Ix^ scH^n spurting urine from time to time. 
The surface of the everted bla^ltler wall is eoveriHl with nmeus 
and iirine^ and the odor of decomposed urine is strong. The urethra 
is generally wanting in these eases, the elitoris is fissured, anil the 
vai^ina and uterus are apt to tx* uiideveloptMl, although st^veral 
ca8t\s of pregnancy occurring in the subjects of exstrophy of the 
blatkler have Ix'en reported. Many of these malformed individuals 
tlie in early chiMhood. Excoriations and ulcerations of the skin 
surrounding the (x^trofnon are generally present Ix'cause of the 
constant escape of urine, and infection of the ureters and kithieys 
is a common complication. The gentTal health is impaired on 
account of tlie l<»ral tlisi-omfort., tlu* eoMi|>lications, and tlie inability 
to jxirform the ordinary duties of life. 



ALTERATIONS IN FORM, AND DISPLACEMENTS 

Distended Bladder. — The shape of the distenrled l)ladder in the 
wonmn is Lletermine^l by its surroundings. The uterus and broad 
ligaments Ix^himl limit its excursion in that direction, thiTefore 
its greatest cUameter when moiierately distc^nflfnl is not longi- 
tudinal, as in the male, but transverse. In extreme disiention 
when the vault ^isf^'^ into the alxlornen the long (hameter is on a 
line drawTi from the base of the bladder to the umbiEcuB. A dis- 
tended l>ladd<T of this sort resembles an ovarian tumor rising from 
the pehns. (Sw Fig. 84a, page 217.) Percussion of tfie anterior 
ab:lomen for a distance of a hami's brea^lth^ more or less, above 
the symphysis, elicits a flat note, and fluctuation may be deter- 
mined by bimanual palpation. The catheter must be passed in 




460 DISEASES OF THE BLADDER 

all doubtful cases, and especially is this precaution necessary if 
there is a history of dribbling of urine. In the case of the overfilled 
bladder the desire to urinate ceases when the distention becomes 
extreme and the repeated involuntary loss of small quantities of 
urine may be the only symptom. If the bladder is very much 
distended the distress and pain in the lower abdomen which ac- 
company the cariier stages of distention may be absent. Patients, 
strange as it may seem, are very apt not to realize that the bladder 
has not been emptied and to give the physician the impression 
that they have been passing their urine, only, perhaps, too fre- 
quently. 

Rupture of the bladder may occur either by violence from with- 
out, as from blows or falls when the bladder is distended, or 
from excessive muscular eflforts on the part of the patient 
herself, as in labor, or in the struggles of anesthesia. Rupture 
is more likely to occur if the bladder wall has been thinned by 
ulceration and sloughing, as well as by distention. It has been 
known to occur in extraruterine pregnancy as well as from all sorts 
of trauma. 

One of the most frequent causes seems to be retroversion of the 
pregnant uterus. Krukenberg and Rivington collected between 
them the reports of twenty cases of this sort. Krukenberg thinks 
that in cases of retroversion and incarceration of the pregnant ute- 
rus the physician should proceed with great caution in replacing the 
uterus, and if portions of gangrenous bladder wall have been passed 
per urethram, abortion should be performed rather than replaco- 
ment, because of the danger of rupturing the bladder during the 
necessary manipulations. Rupture is commonly intra-peritoneal 
and uncommonly extra-peritoneal. The diagnosis of rupture de- 
pends on sudden abdominal pain and collapse. The sound passed 
into the bladder goes an indefinite distance up into the abdominal 
cavity through the rent in the bladder, while the catheter shows 
that the bladder is empty. In the event of extra-peritoneal 
rupture the symptoms are less severe and urinary extravasation 
appears in the course of a few hours. In such case the sound can 
not be passed such a long distance as when the opening is into the 
peritoneal cavity. Sterile salt solution injected into the bladder 
causes no swelling of the viscus as determined by bimanual pal- 
pation if the rupture is intra-peritoneal. Cystoscopy is out of the 



■PLACEMENTS 



461 



quebtion in these cases because of the grave condition of the 

l>atient. The akloinen should be otx^ncd at once. 

Contractioti of the bladder is generally due to cystitis, to inflatiinifi- 
tory iidhei^ious about the liladder, or to a habit of frequently of 
micturition, The symptom is fre(|ueney of uruiation. The diag- 
nosis is established by injecting fluid until the patient has a strong 
desire to urinate or until the Huid is expelled. Measure the amount 
in a glass gratluate. It may be only an ounce or two. By eystos- 
copy the blatltler will not dilate well when air is admittetl and the 
niycous membrane is wrinkled and corrugated; scar tissue will bf* 
im^n if the contraction is ilue to old inHannnator>^ processes in the 
blattder. 

Upward displacement of the bladder not associated with dis- 
tention is met with in tlie case *)f large fibroids of the uterus. The 
bladder is flattened out on the* anterior faee of the tumor ami its 
fundus may even reach as higli as the umbilicus. The relative 
infrequeney of urinary symptoms in these cases has always been a 
s<^^>urcc of surprisi* to me. Palpation of the tumor will show, |>r^^- 
vided the alxtominal walls are lax and thin, an elastic swelling on 
the anterior aspect of the tumor. The passage of the sound into 
the bladdtT permits the mapping out of its confines. This pn> 
cedure should never Ix^ omittnl by tlie surgeon in the diagnosis of 
large fibroids, for the operator should know where the blatlder is 
situated b4?fore he opens the abdomen, rather than cut into it by 
mistake in the courst^ of an o[X'ration for the removal of a tumor — 
a not very ran:* hajq)eiiing. 

Downward displacement of the bladder occurs whenever tlie 
anterior segment of the pelvic floor is displace* I downwanl It is 
generally asstx'iated with uterine prolapse* anil witli rupture of the 
perineum and [xlvie floor. When the ba*se of tlie blatlder [irojects 
into the anterior wall of the vagina the condition is knoipiii as 
eystocele. The iliagnosis of this rondition is to te found in Chapter 
XX., page 366 (set; also Chapter \\, The Mechanics of the Pelvic 
Floor) page 221. It is rare for the entire bladder to be in the sac of 
a complete uterine prolapse, a portion of the organ remaining m tln.^ 
pelvis in almost all cas^^s. When a part of the IjIaddtT is prolapstnl 
and a |>art- is behind the pubie bone the organ may assunie an hour- 
glass shape. Exceptionafly, in the jjresfiief of procidentia, the 
bladder becomes detached from its connections with the vagina 




462 DISEASES OF THE BLADDER 

and remains in its normal situation. The diagnosis of the situation 
of the bladder is established by means of the soimd passed into the 
bladder. (See Fig. 89, page 227.) In cases where the base has been 
displaced the ureteral orifices are displaced also, although they 
always bear the same relation to the internal orifice of the urethra. 

Lateral displacement occurs when an inflammatory mass or tu- 
mor occupies one half of the pelvis, the bladder being obliged to 
expand into the opposite half of the pelvis. Here the asymmetry 
may be determined with a sound, measurements being taken of 
the depth of the bladder in various directions. 

Hernia of the Bladder. — The bladder wall may, very rarely, be 
pushed into the inguinal and femoral canals and form a part of a 
hernia. 

Eversion of the bladder through a dilated urethra is a rare form 
of displacement. The entire thickness of the bladder wall is in- 
volved and the protruded mass appears as a bright red tumor 
projecting from the urethral orifice. The mechanism of the pro- 
duction of eversion appears to be as follows: Given, a large urethra, 
as in the congenital enlargement described on page 444, the patient 
strains excessively, perhaps because of constipation or diarrhea, 
and the posterior wall of the bladder is forced into the neck of the 
bladder and then into the urethra, to present, in the course of 
time, at the external orifice. In extreme instances the entire 
bladder has been found turned inside out through the urethra. 
Eversion is observed most frecjuently in yoimg children, and in the 
very old. The diagnosis is made by noting the ureteral orifices in 
the prolapsed mass, by passing a sound introduced in the urethra 
round the tumor and finding that it is attached nowhere to the 
urethral wall, and by observing that the sound will not pass beyond 
the neck of the bladder. An anesthetic is necessary in order to 
reduce the eversion. WTien the bladder wall has been pushed back, 
the fact that the urethra is dilated will be apparent, and the bladder 
can be filled with fluid, and also inspected with a cystoscope. 

FOREIGN BODIES IN THE BLADDER 

Calculi. — ^The foreign body most frequently found in the bladder 
is a calculus or stone. This may have reached the bladder from 
the kidney through the ureter— in which case the stone is said to 



FOREIGN BODIES IN THE BLADDER 



463 



Ixt primary — or it may have formed in the bladder about mme 
other foreign bo^:ly, s^uch as a silk ligature, or the products of 
inflammation. In the latter event it is a seeondary stone. In- 
eruNlations of phosphate.s antl urates on the bladder walls following 
inflammatory proees.s<'s are the eomnionest forms of ealculi. SmalJ 
urie acid and oxalic acid calculi may come down from the kiilney, 
hlay in the bladder, and attain eonsiilerable size by the accretion 
of layers of deposit of urates and phf»sphates. 
Calculi are raos1 often found in children and in old women. 
The female urethra h short and frequently small stones from 
the kithiey are paiHs^^tl without causing severe symptoms. On the 



Fig. 186.— Stone in the BJiidder. (Knorr.) 

other hand, foreign lK>d!es are introtluced from without much more 
easily than in tiie male, therefore th<? pres^'nce of extraneous 
foreign Ix^Ues and con*seijuently of some form of stone — for foreign 
l»odies are usually eneru^ed aft<T they have been in the bladtk^r 
for any length of time — is more common in the female than in the 
male' bladder. 

Other Foreign Bodies. — Sutjstances introduce*! through the 
urethra are: pieces of catlieters which have broken off, pieces 
of rul)bfT tubing, hairpins, sefnls of cherries aufl other fruits. It is 
a rare but not impossible (X-eorrence for a nurse to break off a glass 
catheter in the bladder. Many of the fenestrated glass catheters 
are weakened by the holes of the fenestrations being too near 




464 DISEASES OF THE BLADDER 

together, and on this account the catheter is more apt to be cracked 
in this situation. 

Once, ten years ago, I was performing an abdominal operation 
for retroversion in a private hospital. This operation had been 
preceded at the same sitting by a curetting and trachelorrhaphy, 
and the precaution of passing the catheter at the close of the va- 
ginal operations had been neglected so that when the abdomen 
was opened the bladder was found to be full. A nurse was asked 
to pass the catheter. She did so, using a fenestrated glass instru- 
ment of the common pattern, and annoimced that there was no 
urine in the bladder. On withdrawing the catheter, however, one 
and a quarter inches of the end were missing. Removing my 
gloves, I passed another catheter and withdrew eight ounces of 
urine. I was then able to palpate by my finger in the vagina the 
broken catheter lying on the base of the bladder. Introducing 
an Emmet curette forceps through the urethra I succeeded in 
pushing the broken glass into the forceps by means of my finger 
in the vagina so that it lay in the long axis of the fenestration of 
the blades. The catheter end was removed through the urethra 
without injuring the bladder or urethra in the slightest degree. 
The broken piece exactly matched its fellow, but the bladder was 
irrigated to make syire that no spicule of glass was left behind. 
The operation was finished and the patient made a convalescence 
free from urinary symptoms. Since this accident I have discarded 
this form of glass catheter and use only the sort that has a single 
opening in the end or side. 

Foreign bodies may enter the bladder from the vagina, the most 
common of these being a neglected pessary, which has ulcerated 
through; or from the abdominal cavity, as a silk ligature which 
was about the pedicle of an ovarian cyst, then became infected 
and reached the bladder by means of adhesive inflammation; or 
the contents of a dermoid or echinococcus cyst which has opened 
into the bladder. The bones of an extra-uterine fetus have been 
known to find their way into the bladder. 

Foreign bodies which remain in the bladder a considerable 
length of time invariably set up a cystitis. This process may be 
limited to a portion of the organ, as in the case where the irritating 
foreign body, especially in the case of stone, is situated in a loculus. 
As a rule, the cystitis is general Large foreign bodies have been 



(Jk'STITIS 



465 



known to ulcerate through the bladder into the vagma or into the 
peritoneal cavity. 

Symptoms* — ^The symptoms of foreign bmlies are those of cys- 
titis: there i.s froqnciicy of mirlurition, pain in the region of the 
bladder, cloudy, perhaps bloody urine, A stone may be carried 
in the bladtler for years without prcKkicing any more symptoms 
than a frec[uency of micturition. A freely movable stone causes 
exaggeration of symi>tom8 on moving alx)ut, especially on ritling 
and driving; it may be at these times only that the urine is bloo<ly. 

Diagnosis. — The diagnosis is maile by pal|mtion and inspection. 
Many foreign bodies may be felt by the finger in the vagina, the 
obbiacles Ix'ing a foreign Ixjdy of small size and a thickened bladder 
wall. The base of the bladder should Ix^ palpated always. The 
sound introduced p^T metliram hits a stone or encrusted foreign 
body with a metallic click. Sometimes a stone in a loculus, or one 
covered with a thick layer of nuicus, will not give this click and 
phospJiatic deposits on an ulcerated area give a gi^atnig feeling to 
the sound similar to that of a round calculus. The drumming of 
the bladder wall on the end of the catheter — ^so-called *'stanmiering 
of the blailder," little taps being given to the catheter,— must not 
be mistaken for the metallic chck. This rlrununing is a physio 
logical affair and may occur in healthy bladders as far a*s we know 
at presimt. It occurs surely in the course of catheterization of 
patients who presi^nt no bladder symptoms. The exact diagnosis 
of stone is matle by iiieans of the cystoscope, the pati(»nt Ix'ing in 
the knee-clu^st c^^loscoj/ic jxjsition. Unless the foreign txHiy is 
a<^lhcrent to the bladder wall it will drop to the most dependent part; 
in any event it may be seen through tlie eysti»scope. 

The electric cystoscopo with wati^r-distended bladtler is well 
adapted for the inspection of small calculi and especially for those 
that are pocketed. (For electric cystoscopy sec Chapter VIII., 
page 117.) 

CYSTITIS 



Inflammation of the bladder is much more infrettuent in women 
than in men. It is a disease of adult life and is esjx^cially common 
at the times of excessive {^elvic congestion, that is, during the 
menstrual [x^riods, in pregnancy, dm*ing congestive pelvic disease, 



30 



466 DISEASES OF THE BLADDER 

and at the menopause. True cystitis is rare during childhood, but 
bactcriuria is not uncommon. (See Chapter XXVIII., page 579.) 

Classification. — Cystitis may be classified as acute or chronic, 
circumscribed dr diffuse, or according to the clinical manifestations. 
Some day a classification based on the bacteriology will be the 
standard. At present a clinical classification seems to be most 
available for diagnostic purposes. The symptoms of cystitis will 
be considered as a whole after the different clinical forms have 
been described. 

Etiology and Pathology. — ^The immediate cause of cystitis is 
always a bacterium. Many sorts of bacteria are found in the 
bladder under conditions of health, just as in the cases of the 
other orifices of the body that are lined with mucous membrane. 
With an unimpaired vis medicatrix naturse the microorganisms 
are short-lived, instance the Klebs-Locffler bacillus in the nose; 
given impaired vitality and the germs find lodgment and flourish 
in the tissues. The following bacteria have been isolated from 
the bladder, almost always in mixed infections: 

bacillus coli communis, gonococcus, 

streptococcus pyogenes, typhoid bacillus, 

staphylococcus pyogenes, tubercle bacillus, 

staphylococcus albus, bacillus proteus, 

staphylococcus aureus, bacillus lactis aerogenes, 

staphylococcus citreus, bacillus pyocyaneus, 

urobacillus liquefaciens. 

In other words, almost any bacterium may, under favorable 
conditions, enter the bladder and cause a cystitis. What are the 
avenues of entrance and what are the favorable conditions? The 
microorganism may reach the bladder (a) through the lu-ethra, 
as in the case of the gonococcus, which, as far as known, always 
gets into the bladder by this channel, (b) through the lu-eter, as in 
the case of the tubercle bacillus, which usually descends to the 
bladder in this way, (c) by the blood current, — ^the typhoid bacillus 
may come in the blood, and (rf) by direct extension through the 
tissues from an adjoining organ, as in the case of the bacillus coli 
communis entering the bladder through the walls of an adherent 
and inflamed bowel. 



C\'STITTS 



467 



Tlie favorable conditionjs — -the predisposing causes — are: (1) 
local, or (2) general 1. Local causes are injuries of the liWlder, 
either direct trauma inflicted on its mucous membrane, or on the 
musculature of the wall, as instnimentation iluring difficult lalxir, 
rough catheterization with a hard catheter, or from stone or othcT 
foreign body in the l>la<liler, or by displacements of the bladder. 
as from the injicies resulting from childbirth ^ from tumors, or from 
overdistentiou. Pregnancy and the catamenia must be regarded 
as local caujses, for at these times the congestion of the pelvic 
organs is pronouncefl, and observation has sho\^^ that cyst-itis is 
more apt to begin then, and if it has existed previously exacer- 
bations are more cominon Ixjth just Ix^fore the menstrual pc;riodH 
and during pregnancy and the puerperium. An>ihing that excites 
and contiimes congestion of the pelvic organs must be regarded as 
a cause of cystitis, and therefore excessive vener>^ or mastiu-bation 
may Iiave an etiological significance. Infiamnaation of adjacent 
orgsms is a local cause in many gynecological cases, as inflammation 
of the tulx\s, a pelvic abscess, or dermoid cyst discharging mto the 
bWlder, or uterine cancer. 

2. Among the general causes are to be classed certain drugs 
taken by the mouth, as cantharides and turpentine, which cause 
congeMion of the vesical mucosa and therefore are causes of in- 
flammation, also alcohol taken in excess. Lowereti vitality and 
anemia are caused by the wasting diseases, also by any acute 
dis(»ase. Skene said that he had noteil that in rneask\s and scarlet 
fever the mucous membrane of the bladder suffered like the mu- 
cous membranf?s elsewhere in the tody in these diseases. 

Chroiuc heart disease and cirrhosis of the liver prmhice engorge- 
ment of the jx^lvic organs; old jige, by tliininishing the tonicity 
of the bladtler walls, favors retention and tlecom|>osition of urine; 
and paralysis, in the same way, may promote retention, overdis- 
tentiou, and decomjxisition. Major operations, by depn?ssing the 
stxength and powers of n^sisiance of the system, may be reckoned 
among the causes. "Catching cold^' must be regarded as a local 
congestion of unknown origin, which often is the only cause afforded 
by the historj^ f»f the casc^. 

Colarrhal Cystitis. — ^The mucous membrane of the bladder is of 
a deeper shade of pink than nonnal, and there is an increase in the 
number and the size of the visible blood-vessels. The condition is 




468 DISEASES OF THE BLADDER 

an exaggeration of the hyperemia seen during menstruation and 
pregnancy. No one can say when hyperemia shades into inflammar 
tion, therefore very little will be said of hyperemia and local hypere- 
mia of the trigone, for instance, and "trigonitis" will be classed 
as localized cystitis. 

Ulcerative Cystitis. — ^With ulceration there is a loss of epithelium 
in the mucous membrane. An excavation can be seen lined by 
granulation tissue, which bleeds on the slightest touch. There 
may be pus, granular debris, or urinary salts on the surface of an 
ulcer, and, in the healing stage, ridges and irregular elevations arc 
visible. 

Exfoliative Cystitis. — ^This is a rare form of cystitis in which the 
mucosa is shed in part or as a whole, with subsequent regeneration. 
It is due, apparently, to the cutting off of the blood supply of the 
bladder caused most often by retroflexion of the pregnant uterus, 
or by protracted delivery. It is an ischemic necrosis, with or 
without bacterial infection. The detached mucous membrane is 
passed per urethram either in small pieces or in one large piece, 
and is apt to be covered by uric acid crystals and to be so much 
disorganized that the recognition of it as mucous membrane is not 
easy. In severe grades, as poiiited out by Boldt, the muscular or 
even the peritoneal coats of the bladder may be involved. 

TvberciUous Cystitis. — ^Tuberculous cystitis is a frequent affection 
and, in the vast majority of cases, is secondary to tuberculous 
disease of the kidney, the infection coming to the bladder through 
the ureter. Rarely it is primary in the bladder, and it may be a 
part of a general tuberculosis. If the disease is secondary to 
tuberculosis of the kidney the manifestations in the bladder are 
most marked in the neighborhood of the ureteral orifice on the side 
of the affected kidney, because in this situation the infected un- 
diluted urine comes into most intimate contact with the mucosa. 
Tuberculosis of the kidney is generally unilateral in its earlier stages. 
The ureteral mens is puffy and swollen, and glistening opaque 
tubercles and ulcerations are seen in the mucosa surrounding the 
orifice. The disease is seldom seen before the ulcerative stage, 
although there is a catarrhal stage which precedes it. In the 
course of time caseation occurs and the tubercles break down, 
leaving a deep, ragged-edged ulcer; the urine containing pus, blood, 
and mucus. The disease may be confined to definite patches in 



fT.STITIS ^■jH 469 

the bladder; the trigone, ba-^e, and posterior walls being most 
often involved; the ulcerations advance slowly in any event; in 
very bad easels the entire Wadder may be ulcerated. 

Tlie dis«'aj^^ runs a ehronie course of many years* duration. In 
making the diagnof^iH of tiil>erculou8 cystitis the history is of aiil, 
and if gonorrhea can bc^ ruleil out in a jiatient having a distinct 
family history of tuJxTculosis, the prol)ability is that the disease 
is tuberculous, especially if the cystitis occurs in a young wonian. 
The appearances of the bladder are more or less charaett ristic: 
glislening, opaque tubercles on a reddened })a'^e, breaking down 
to form ulcers with irregular sharp eilges and granulating bases. 



^. 



Fro, liS7.— TuberculoBia of the Left Ureter and Bla<i<Ior, Showing Crater-like 
rretera! Orifice ui*d TulH?rcles of the Bladder Wall. (Knorr,) 

In the late stages thr* bladder shows eontractiHl areas and uleera- 
tiom?. Finding the tuljercle IjacilJi in the urine makes the iliagnosis 
positive. In the early stages of the diseas*:^ they may be few in 
number and hard to fiml; later, there will lx» no tJifficulty, as 
abundant bacilli are in the urinary sediment, 

llunner and Ciisper have bei*n al>le to find tulRTcle bacilli in 
eighty per cent of all their cases of tuberculosis of the urinary sys- 
tem, Hunner gives the following steps of his teelmtque for finding 
the bac*illi: — A catheterized sfx^cimen of urine is allowed to stand a 
few hours in a conieal urine glas.s; 5 to 10 cubic centimeters are 
taken from the bottom with a pi|K4te and centrifugalized. The 
hea\'y deposit is si)rf»ad on two glass slides that have lx*en pre- 




470 DISEASES OF THE BLADDER 

viously cleansed of grease by alcohol, and are allowed to dry in 
the air or in th^ incubator. These slides, after fixing by heat, are 
stained in the usual manner by carbol-fuchsin, then they are 
decolorized with a three-per-cent nitric or hydrochloric acid alcohol 
solution, and counterstained with methylene blue. Half an hour 
Is spent in the examination of each slide under the microscope. 

Inoculation of a guinea-pig is an easy and sure way of estab- 
lishing the diagnosis of tuberculous cystitis. By means of a h3rpo- 
demiic sjTinge suck up a little of the urinary sediment and inject 
it under the skin of the groin of a guinea-pig, having first washed 
and shaved the area. If tubercle bacilli are present the enlarged 
inguinal glands will be felt as distinct nodules in the course 
of two or three weeks. A gland removed, sectioned, and stained 
will show the characteristic lesions of tuberculosis and the 
tubercle bacilli. 

In doubtful cases pick off a bit of tissue from the edge of the 
ulcerated area in the bladder, using the cystoscope and the alligator 
forceps, and stain and examine the tissue for tubercle bacilli. 

Rare Forms. — Certain rare forms of cystitis have been describeil. 
Of these vesicular cystitis consists of the appearance of minute 
vesicles, the size of a pin's head, on a congested bladder mucosa. 
These vesicles may be arranged in bead-like strings on either side 
of the blood-vessels and are regarded as dilated lymphatics. Larger 
vesicles amounting to bullae have been described as occurring in 
the bladder. The little vesicles arc not to be confused with the 
tubercles of tubercular cystitis. The vesicles are shiny, translu- 
cent, and have no red base, as in the case of the tubercle. The 
tubercles are opaque and are never arranged in rows. 

Several observers have noted the occurrence in the bladder of a 
patch of horny, epithelial cells arranged in layers, a comification 
of the mucosa. A. T. Cabot {Ainer, Jour. Med, Set,, Feb., 1891) 
described a case in which a membrane of whitish-yellow color and 
hard to the touch, in size forty-five square centimeters and two 
or three millimeters in thickness, was removed by him from the 
posterior wall of the bladder of a man of forty by suprapubic 
cystotomy. The membrane was composed of epithelial cells 
arranged as they are on the surface of the skin. Virchow found a 
similar condition of the mucous membrane of the larynx that he 
called " pachydermia laryngis." 



CYSTITIS 



471 



Gierke, according t<3 Huiuier, tk*t^<Tibt*<l two eases and found 
seven others in the literature with the following characteristics; — 
Soft ncMkiles or plaqui^s of a ycllnwisli or yellowish-gray color sit- 
uatetl in the mucous nienibram' and submucosa of the bladder 
presc^nting an appc*arance not unlike the Peyer\s patches of the 
intestine in typhoid fever. They are round or oval, isolated or 
eorniectiHl, and vary in s'w^ frofti one millimeter to two centiineter-s 
in diameter. The mucosa surrounding a plar[ue is riHlclene*]. They 
have no characteristic arrangement an<l their jmthology and etiology 
arc olyscure. 

Symptoms of Cystitis.— Tlie chief sjTuptom of cystitis is frequency 
of passing urine accompanied by pain, it btnng most marked when 
the seat of the tlisease is near the neck of \hv bla